
Class. ,. 



Book 






TIESE 



MODERN THERAPEUTIC 

SERI _E o. 



I. MODERN MEDICAL THERAPEUTICS--*- Compendium 

of Recent Formulae and Specific Therapeutical Directions, 
from the Practice of Eminent Contemporary Physicians, 
American and Foreign. By George H. Napheys, A. M., 
M. D., etc. Seventh Edition, enlarged and revised to 
1880. 1 vol. 8vo. Pp. 608. Price, cloth, $4.00 ; sheep, 
$5.00. 

II. MODERN SURGICAL THERAPEUTICS-a Compen- 

dium of Current Formulae, Approved Dressings, and Spe- 
cific Methods for the treatment of Surgical Diseases and 
Injuries. By George H. Napheys, A. M., M. D., etc. 
Seventh Edition, 1881. 1 vol. 8vo. Pp. 601. Price, 
cloth, $4.00 ; sheep, $5.00. 

III. THE THERAPEUTICS OF GYNECOLOGY AND 0B- 

STETRICS — Comprising the Medical, Dietetic and Hy- 
gienic Treatment of Diseases of Women, as set forth by 
distinguished contemporary specialists. Edited by Wm. 
B. Atkinson, A. M., M. D., etc. 1 vol. 8vo. Pp. 560. 
Price, cloth, $4.00 ; sheep, $5.00. Second greatly enlarged 
edition, 1881. 

*** Any of the above works sent by mail, post-paid, on receipt 
of the price, by the publisher. 

D. G. BRINTON, 

115 South 7th Street, Philadelphia. 



THE 



THERAPEUTICS 



OF 



Gynecology and Obstetrics 



COMPRISING THE 



Medical, Dietetic, and Hygienic Treatment 



OF 



Diseases of Women. 



SECOND EDITION, THOROUGHLY REVISED AND GREATLY ENLARGED. 



EDITED BY 

WILLIAM B. "ATKINSON, A. M., M. D., 



AUTHOR OF HINTS IN THE OBSTETRIC PROCEDURE, LECTURER ON DISEASES OF CHILDREN 
AT THE JEFFERSON MEDICAL COLLEGE ; PHYSICIAN TO THE DEPARTMENT OF 
OBSTETRICS AND DISEASES OF WOMEN, HOWARD HOSPITAL ; CORRES- 
/ f) PONDING MEMBER OF THE GYNECOLOGICAL SOCIETY, BOS- 

TON ; FELLOW OF THE AMERICAN ACADEMY OF 
MEDICINE ; HONORARY MEMBER OF 
THE MEDICO-CHIRURGICAL 
SOCIETY, BOLOGNA, 
ITALY, ETC. 



^v 



PHILADELPHIA 



D. G. BRINTON, 115 SOUTH SEVENTH STREET. t.fi 

l88l. 







Entered according to Act of Congress, in the year 1831, by 

D. G. BRINTON, 

In the Office of the Librarian of Congress. 

All rights reserved. 



PUBLISHER'S NOTICE 



The present volume is the third in the Series of " Modern 
Therapeutics," originally projected by the late Dr. Geokge H. 
Napheys, but which his death prevented him from completing. 
The work has been finished under the able supervision of Dr. 
"Wm. B. Atkinson, whose wide experience in this branch of pro- 
fessional study is a sufficient guaranty that it has been well done. 

The aim of the Series is to present the most modern and ap- 
proved plans of treating the diseases considered, as set forth by 
the most eminent authorities and specialists in this country and 
Europe. The word Therapeutics is taken in its widest sense, in- 
cluding all efficient means of combating disease, not only phar- 
macal, but hygienic, dietetic, climatic and specific as well. A 
number of authors are quoted, and their views accurately pre- 
sented. When they differ, as is not infrequently the case, no 
magisterial attempt is made to decide which is in the right, as 
this difference of opinion is evidence that further observation and 
a very wide induction are demanded to reach a positive decision. 
It is better that such difference should be noted by practitioners, 
and that the circumstances of the case and its surroundings 
should be the guide to the selection of remedial measures. 

The u Resumes of Remedies," added to each disease, are in- 
tended to set forth, in alphabetical order, all the agents which 
have been recommended in its treatment by good, recent authori- 
ties. New methods and recent additions to the Materia Medica 
are given special attention, but only such admitted as appear to 

v 



vi publishek's notice. 

have solid evidence in their favor. Those of special value are 
marked with an asterisk (*). In this department recent medical 
periodical literature has been closely scanned for information, and 
references are given to special articles and monographs. 

Substantially the same plan is carried out in all the volumes 
of the series, and the favorable reception which the Medical 
Therapeutics and the Surgical Therapeutics have met with, in- 
duces a hope that the present volume will be found not less 
serviceable to the practicing physician. 



EDITOR'S PREFACE 

TO THE PIBST ZEXDITIOUST 



In compliance with the wish of the publisher, the editor of 
the present volume has carefully reviewed the material prepared 
for it, and has added extensively from recent treatises, mono- 
graphs and journals, containing matter on the two- specialties 
represented. The great activity which has been manifested of 
recent years in these branches, particularly that of Gynecology, 
renders it almost impossible for a physician who has to attend to 
a large general practice to follow the rapid advance in therapeutic 
methods which has taken place. This work is designed to pre- 
sent him all of these which are worth his attention ; great care 
has been exercised that nothing of ascertained value should be 
omitted ; and the editor believes that very few omissions of this 
character will be found. 

In accordance with the plan preferred by the publisher, pre- 
cise directions in the plans of treatment have been preserved, and 
the exact formula? presented whenever these could be obtained. 
Undoubtedly, in some instances, the therapeutic vagueness which 
is fashionable in many books on practice at the present day, is 
largely chargeable with the distrust of remedial measures often 
encountered among medical men. 

It has been deemed best to preface each chapter with a " Syn- 
opsis of Diagnostic Points," setting forth, in brief but clear forms, 
the distinctive signs and symptoms between the diseases consid- 
ered in the chapter. This permits the etiological plans of treat- 
ment to be presented more distinctly, and may also serve as a 
reminder in cases of puzzling similarity. 

vii 



PREFACE 

070 THE SZECOZSTMD EZDITIO^T. 



In preparing the second edition of this work, not only has the 
text of the previous edition been carefully corrected, but nearly 
two hundred additional pages of new matter have been added. 
The material for this has been drawn largely from a collation 
of the most recent German, French and English writers on this 
subject ; the works of many of the former have never been trans- 
lated, and hence are entirely new to the American public. Every 
effort has been made to render their teachings accurately and 
with sufficient fullness. 

The extent of the revision may be judged from the fact that 
the index of authorities contains one hundred and nineteen addi- 
tional names over that of the first edition. Various methods of 
treatment of diseases and complications, omitted in the previous 
edition, will be found in the present one, of which we may 
specify Balneo-therapy in Diseases of Women, Antiseptics in 
Labor, Disorders of the Eyes in Pregnancy, Place nta-Prsevia, 
Coccygodynia, Foetid Menstruation, etc. It is believed that the 
work, as it is now issued, is a faithful presentation of the most 
approved therapeutic methods in diseases of women as set forth 
by the most eminent authorities of modern times. 

Philadelphia, October, 1881. 

viii 



TABLE OF CONTENTS. 



PAGE. 

Publisher's Notice 3 

Editor's Preface 5 

Preface to the Second Edition 6 

Table of Contents 7 



PART I. 
GYNECOLOGICAL THERAPEUTICS. 



INTRODUCTORY. 



General Eemarks on the Treatment of Diseases of Women... 17 

Balneo-therapy in Diseases of Women 21 

Plan for a Gynecological Examination 24 



CHAPTER I. 

DISEASES OF THE OVAEIES, DISOEDEKS OF MENSTKUATION, 
AND GENEEAL DISEASES. 

Synopsis of Diagnostic Points 27 

Ovaritis 27 

Ovarian Tumors 28 

Amenorrhoea 32 

Dysmenorrhea 34 

Menorrhagia and Metrorrhagia 34 

ix 



X TABLE OF CONTEXTS. 

PAGE. 

Chlorosis and Anaemia 36 

The Change of Life 36 

Ovaritis (Acute, Subacute and Chroxic) 38 

Ovarian Neuralgia 41 

Ovarian Dyspepsia.... 42 

Ovarian Hyperemia 43 

Acute and Chronic Ovaritis ". 43 

Resume of Remedies 44 

General Methods 45 

Ovarian Tumors 45 

Internal Medication 45 

Injections into the Sac 46 

Electrolysis 46 

Amexorrhcea 48 

Menstruation is and always has been absent 48 

Menstruation is scanty f>r irregular 49 

Suppression of the Menses 49 

Chronic Suppression 50 

Plethoric Amenorrhcea 53 

Nervous Amenorrhcea 54 

Tuberculous and Scrofulous Amenorrhcea 54 

Amenorrhcea by Counter Fluxion 54 

Amenorrhcea from Anaemia and Chlorosis 56 

Resume of Remedies 5S 

General Measures 63 

Dysmexorrhcea 64 

Neuralgic Dysmenorrhcea 64 

Congestive Dysmenorrhcea 65 

Obstructive Dysmenorrhcea 65 

Membranous Dysmenorrhcea 65 

Ovarian Dysmenorrhcea 6Q 

Neuralgia of the Uterine Neck 68 

Spasmodic Dysmenorrhcea 68 

Dysmenorrhcea from General Causes 68 

Dysmenorrhcea through Insufficiency 68 

Menorrhagic Dysmenorrhcea 68 

Irregular Dysmenorrhcea 68 

Rheumatic Dysmenorrhcea 68 

Membranous Dysmenorrhcea 74 

Resume of Remedies 76 

Foetid Menstruation 77 

Mechanical Remedies 80 



TABLE OF CONTENTS. XI 

PAGE. 

Menorrhagia and Metrorrhagia 81 

Passive Hemorrhage 81 

Resume of Remedies 89 

Vaginal Injections 96 

Hysteria 98 

Eesume of Remedies 102 

External Remedies 104 

Chlorosis 105 

Resume of Remedies 108 

The Climacteric Epoch, or the Change of Life 110 

Resume" of Remedies 113 



CHAPTER II. 

DISEASES OF THE UTERUS AND ITS ANNEXES. 

Synopsis of Diagnostic Points 115 

General Observations 115 

Uterine Symptoms 116 

Uterine Inflammations . 117 

Metritis and Cervicitis 118 

Endometritis and Endocervicitis 119 

Metritis (Non-Puerperal, Endo-, Peri-, Para-Metritis, Uter- 
ine Catarrh, Etc.) 120 

General Treatment 120 

Local Treatment 121 

Chronic Endometritis 122 

Chronic Metritis 125 

Chronic Parenchymatous Metritis 126 

Uterine Dyspepsia 127 

Perimetritis 127, 132 

Pressure in Uterine Diseases 135 

Intra-uterine Medication.., 136 

Uterine Injections 136 

Medicated Injections 137 

Pledgets (Pinceaux) 140 

Crayons or pencils 140 

Ointments and Glyceroles 141 

Capsules 142 

Powders , 143 

Pessaries or Intra-uterine Tents 143 



Xll TABLE OF CONTENTS. 

PAGE. 

Resume* of Remedies 143 

External Measures 144 

Cerviticis (Ulceration and Granulation of the Os, Etc.) 146 

Indolent Ulcers 146 

Inflamed Ulcers 146 

Fungous Ulcers 146 

Senile Ulcers , .. 146 

Diphtheritic Ulcers 146 

Caustics 149 

Ignipuncture 150 

Topical Use of Ergot 156 

Interstitial Injection 160 

Mechanical Treatment 162 

Tents for Dilating the Cervix — 164 

Resume of Remedies 167 

Uterine Tents .. 170 

Other Measures 172 

Displacements 173 

Retroversion and Anteversion 173 

Anteflexion 175 

Prolapsus of the Uterus 175 

Inversion of the Uterus 176 

Pessaries 176 

Flexures of the Uterus , 181 

Procidentia.... 182 

Chronic Inversion of the Uterus 183 

Rules for the Use of Pessaries 184 

Non-Malignant Growths 190 

Polypi 190 

Fibrous Growths 193 

The Medical Treatment of Uterine Tumors 197 

Resume of Remedies 203 

Other Measures 205 

Malignant Growths 206 

Cancer 206 

Epithelial Cancer 210 

Sterility and Anaphrodisia 212 

Resume of Remedies 219 

Nymphomania 220 

Resume of Remedies 220 



TABLE OF CONTENTS. Xlll 

CHAPTER III. 

DISEASES OF THE VAGINA, URETHRA AND BLADDER. 

PAGE. 

Synopsis of Diagnostic Points 223 

Vaginitis 223 

Cystitis 225 

Urinary Disorders 225 

Vaginitis, Acute and Chronic — Vaginal Catarrh — Leucor- 

rhcea — Colpitis 226 

Vaginal Injections 226 

Vaginal Irrigations 226 

Medicated Tampons 227 

Vaginal Cataplasms 227 

Resume of Remedies 236 

Vaginal Injections 237 

Vaginal Suppositories ...; 243 

Vaginitis (Specific, Gonorrheal) 244 

Gonorrhceal Cervicitis 247 

Gonorrheal Acute Ovaritis 247 

Gonorrhceal Metritis 248 

Vaginismus and Dyspareunia 250 

Resume of Remedies 254 

Vaginal Growths 255 

Caruncle of the Urethra 255 

Non-Syphilitic Warts 256 

Vegetations, flat and horny 256 

Pruritis Vulvae seu Vaginae and Vulvitis 257 

Eczema Genitale 269 

Resume of Remedies 270 

Cystitis 276 

Urethritis 281 

Catarrhal Urethritis 281 

Urinary Disorders— Irritable Bladder, Dysuria, Polyuria, 

Ischuria, Etc 285 

Vascular Growths 286 

Irritable Bladder 287 

Incontinence of Urine , 287 

Paresis of the Bladder 289 

Neuralgia of the Bladder : 290 

Urethrocele 291 



xiy TABLE OF CONTENTS. 

PART II. 

OBSTETRICAL THERAPEUTICS. 



INTRODUCTORY. 

PAGE. 

Case-taxing in Midwifery , 295 



CHAPTER I. 
THE DISORDERS OF PREGNANCY. 

The Hygiene of the Puerperal State 299 

Food 300 

Clothing 300 

Exercise • 301 

Sleep . 301 

Mental Condition .. 301 

Marital Relations 301 

Abortion and Premature Labor 302 

Induction of Premature Labor 315 

Resume of Remedies 321 

Uterine Sedatives and Tonics 321 

Ecbolic and Abortifacient Agents 322 

Vomiting and Nausea, of Pregnancy 325 

Resume of Remedies 332 

Internal Remedies 332 

Local Measures 335 

Sympathetic Nervous Disorders ' 337 

Palpitation 337 

Syncope 337 

Neuralgia 337 

Headaches 337 

Insomnia 333 

Hypochondriasis 338 

Nervous Cough 338 

Cutaneous Affections 339 

Pruritus 339 

Urticaria 341 

Herpes Gestationis 341 



TABLE OF CONTENTS XV 

PAGE. 

Ephelides 341 

Diseases of the Eyes 341 

Digestive Derangements of Pregnancy 344 

Gingivitis, Puerperal Salivation 344 

Diarrhoea 345 

Constipation 345 

Icterus Gravidarum 346 

Hermorrhoids 346 

Albuminuria of Pregnancy 348 

Hydremia 352 

Eesume of Eemedies 352 



CHAPTER II. 

COMPLICATIONS, DISOKDEES AND SEQUELAE OF PAETUEI- 

TION. 

Anesthetics in Labor 355 

Conclusions on ,.. 358 

Propositions on , '. 

Eesume of Eemedies 361 

Antiseptics in Labor 364 

Antiseptic Uterine Post-partum Injections 372 

Placenta. Previa 375 

Various Methods in 375 

Tedious Labor 378 

Eigid Os and Atony of Uterus 378 

Feeble or Irregular Action 381 

Eesume of Eemedies 384 

External Measures 387 

After-Pains 3S9 

Eesume of Eemedies 398 

Puerperal Hemorrhage 399 

Eesume of Eemedies 413 

General Measures 416 

Puerperal Eclampsia 419 

Eesume of Eemedies 426 

General Measures 42S 

Puerperal Mania 430 

Treatment of Uterine Disease in Insane Women 435 

Puerperal Fever (Puerperal Septicemia, Puerperal Pyemia,) 439 

Eesume of Eemedies 462 

General Eemedies 463 



XVI TABLE OF CONTENTS. 

PAGE. 

Puerperal Thrombosis and Embolism 465 

Hsematoma 467 

Puerperal Shock 469 

Pelvic Cellulitis and Peritonitis (Puerperal Phlebitis and 

Metritis) 470 

Diagnostic Points 470 

Puerperal Metritis 475 

Puerperal Peritonitis 477 

Resume of Eemedies 480 

Other Measures 481 

Phlegmasia Dolens 483 

Milk Fever 488 

Puerperal Convalescence 491 

Retarded Involution 492 

Laxatives for Puerperal Women 492 

Coccygodynia 494 



CHAPTER III. 

DISEASES OF THE MAMMARY GLANDS AND OF LACTATION. 

Mastitis and Mammary Abscess 497 

Resume of Remedies 509 

General Measures ... 511 

Mammary Tumors 513 

Diagnostic Points 513 

Hysterical Breast 514 

Mammary Neuralgia (Mastodynia) 523 

Galactorrhea 524 

Resume of Remedies 528 

Agalactia and Oligogalactia 531 

Means to Increase the Milk 531 

Means to Re-establish Lactation 531 

To Prevent Accidents from Sudden Cessation 532 

Galactagogues 533 

Food as a Remedy 535 

Resume of Remedies 536 

Diseases of the Nipples 538 

Resume of Remedies 548 



GYNECOLOGICAL THERAPEUTICS. 



INTRODUCTORY. 



Before proceeding to the consideration of the therapeutics of 
particular diseases, some suggestions will be quoted as to the 

GENERAL MEDICAL TREATMENT OF DISEASES OF 

WOMEN. 

DR. C. CHROBAK, OF VIENNA.* 

In the modern treatment of diseases of females, the attention 
of physicians is more fruitfully addressed to defining the indica- 
tions for the use of known remedies, than to the search for 
specifics. Of recent years, the introduction of so many mechani- 
cal aids into gynecology has led to an undue depreciation of 
the value of internal and general medication. There is no doubt 
but that cases which admit of local as well as general treatment 
recover more rapidly, but it is unwise and injurious to neglect 
the latter, as is often done. 

Besides the general rules for indications and contra-indications, 
there are, in the treatment of women, many conditions to con- 
sider, which have reference to their psychical character and to the 
peculiar seat of the disease. It is not rare to see unpleasant com- 

*Handbuch der Frauenkrankheiten, I. Edited by Billroth. 1879. 

2 17 



18 GYNECOLOGICAL THERAPEUTICS. 

plications arise from any attempt at local treatment, and im- 
provement commence when this is wholly suspended and measures 
addressed to the general system alone are employed. Local 
treatment is occasionally observed to increase the nervous irrita- 
bility, to develop severe hysteric attacks, and even lead to mental 
alienation. 

What lead to such conditions are the heightened sexual sensa- 
tions, the sense of shame, the obligatory continence often required, 
and a number of similar emotions. When they lead to the results 
mentioned, all local interference should be suspended, and the 
erethism of the system reduced by anodynes, warm baths, exer- 
cise, change of air, scene and society, etc. Hydropathic treatment 
has a high reputation in such cases, but the procedures employed 
in institutions devoted to this branch are often too decided to 
exert good results on an over-excited nervous organization. Dr. 
C. has himself derived very positive benefits from the use of 
oxygen inhalations in allaying such general nervous erethism. 

It is evident, therefore, that before any treatment is under- 
taken, the psychical condition of the patient should be carefully 
considered. There are some cases — fortunately not many — in 
which local treatment must be absolutely prohibited from the 
outset. In others, it should only be commenced after a prelimi- 
nary general treatment. The patient must be convinced of the 
necessity of the local measures. They should be explained to 
her, and she should be assured that only the most indispensable 
examinations, etc., will be conducted. The moral support of the 
patient should be sought for, and her confidence in the operator 
heightened as much as possible. 

The physical strength should be maintained at the highest 
point during local treatment. Feeble individuals, and those 
. suffering from dyspeptic, gouty and other constitutional mala- 
dies, should receive treatment with a view to lessen these com- 
plications. Here is where health resorts, medicinal springs and 
sea bathing come happily into play, and will often be very effi- 
cacious. 

All local treatment is to be avoided, when possible, during 



TREATMENT OF DISEASES OF WOMEN. 19 

pregnancy, for fear of leading to abortion or premature delivery. 
So far as the mother herself is concerned, it is probable that her 
risks under operations while in this condition have been unduly 
magnified by some writers. Lactation is another period which 
should not be chosen for local treatment unless the demand is 
urgent, inasmuch as the concomitant dietetic measures, enforced 
rest, etc., will very probably interfere with the secretion of the 
milk. The menstrual period was long considered to contra- 
indicate any kind of local treatment. As a general rule, the in- 
creased hyperemia of the parts may be supposed to justify this, 
but for some operations, on the contrary, it is just the period to 
select. Thus Simon has shown that in plastic operations on the 
female genitals, healing by the first intention is favored by the 
congestion which then prevails. In a general way it may be 
said that the most favorable period at which to begin local treat- 
ment is a few days after the menstrual flow has ceased. 

In regard to cohabitation during local treatment, it must be 
considered, in nearly all cases, as positively injurious and to be 
prohibited. It induces local hyperemia, and increases the nerv- 
ous irritability ; and as it may also lead to pregnancy, and thus 
completely interrupt the progress of the treatment, it is best to 
discourage it altogether. 

Women experience the sensation of pain in very different de- 
grees. Robust and vigorous ones may suffer greatly from a slight 
operation which a feeble and sickly person will bear without com- 
plaint. As severe pain acts injuriously on the nervous system, 
it must be avoided by the administration of anaesthetics. It may 
be observed that the vagina is less sensitive than the external 
genitalia, and that the vaginal portion of the cervix is scarcely 
at all sensitive in its ordinary condition. For general anaesthesia 
the same rules apply as in surgery, and the same contra-indica- 
tions. They may be administered in the knee-elbow or any 
other position, but it is essential to have a competent assistant 
present to give the anaesthetic. 

Of the anaesthetics employed, chloroform and ether continue to 
be the most popular, or a mixture of both with alcohol. Several 



20 GYNECOLOGICAL THERAPEUTICS. 

gynecologists, as Spencer Wells, Hegar and Kaltenbach, 
have lauded the bichloride of methylene. It should be noted that 
when the finger or an instrument is introduced rather rudely 
into the rectum or vagina of* a patient under anaesthesia, it is 
followed by hoarse, stertorous breathing, which is not, however, 
of alarming significance. 

Local anaesthesia is not very reliable in operations about the 
vagina, and is mostly confined to parts easy of access and small 
operations, as puncturing an abscess, etc. As such may be men- 
tioned ice, cold mixtures, vapor of ether and chloroform, and 
compression. Of these the most efficient is the ether pulverizer 
of Richardson. 

In recent years, massage has been introduced into gynecology 
as an efficient means in causing the absorption of deposits, in 
restoring vigor to atonic muscles, and in diminishing local irrita- 
bility. Brandt, of Stockholm, has laid down the details of the 
method, and advocated it in an extensive line of maladies of the 
uterus and its annexes. His recommendations have not been 
well received by gynecologists in general, and it is alleged that 
grave accidents have at times followed the manipulations. But 
it cannot be denied that in some cases excellent results have been 
obtained when all other resources of medical art had failed. 

The most serious difficulty seems to be in the disagreeableness 
to the patient to have the genitalia subjected to the prolonged 
manipulation required. The essential element of massage is in- 
termittent pressure. This may be obtained by centripetal stroking 
and rubbing with the hand and fingers. The part operated on 
should have a firm base, as one of the pelvic bones, etc. Brandt 
advises also light taps, repeated pressure with the finger tips, etc., 
sometimes on the outer surface of the abdomen, sometimes with 
the finger in the vagina. The operator may also take the uterus 
between the fingers of both hands — the one in the vagina, the 
other externally — and exercise upon it gentle, continued or inter- 
mittent pressure. The massage should be at first very gentle and 
continued but for a brief session ; later the pressure may be in- 
creased and the time prolonged, the rule being that increased 



BALKEO-THERAPY IX DISEASES OF WOMEN. 21 

painfullness is a sign to discontinue. Ziemssen recommends that 
it be applied in a warm bath. After the process the patient 
should remain for some time in entire rest, as the operation is 
followed by decided local hyperemia. 



BALNEOTHERAPY IN DISEASES OF WOMEN. 

In the United States, comparatively little systematic attention 
has been paid to the treatment of diseases of women by mineral 
and medicinal waters. We therefore select from one of the most 
recent German works on this subject, by Dr. Ignaz Meyr, 
(Anleitung zur Wahl der Curorte, Wien, 1880,) the principles 
which, iu Europe, have been proven most efficient in this method 
of therapeusis. 

Dr. Meyr states that balneo-therapy has fully vindicated its 
value in this class of maladies. This is especially true of chalybe- 
ate water, sulphur springs, those holding in solution iodine and 
bromine, and the sool or saline baths. 

The diseases in which the best effects have been observed are 
the anomalies of menstruation, affections of the uterus and 
ovaries, and in sterility. 

Where the menstruation is deranged, with concomitant anaemia, 
dyspeptic symptoms, nervous irritability and loss of vigor, cha- 
lybeate waters may be advantageously used both internally and 
as baths. In lymphatic and scrofulous subjects, sea bathing is 
to be recommended, as also in membranous dysmenorrhea. The 
ascending douche is a powerful agent, for which the necessary 
apparatus may be found at many European springs, as at Franz- 
enbad, Pyrmont, etc. In sluggish temperaments, where painful 
menstruation is not associated with any change in the texture of 
the uterus, local baths of dry carbonic acid gas are indicat d. 
Where the nervous erethism is marked, the prolonged use of the 
cold water treatment is often efficacious. 



22 GYNECOLOGICAL THEKAPETTTICS. 

In coDgestive dysmenorrhcea, with chronic metritis aud indura- 
tion, such sool baths as are found at Ischl, Ginunden, etc., or 
the iodine and bromine waters of Heilbronn, Kreuznach, etc. 
prove themselves of value. 

When menstrual irregularity proceeds from disturbance of the 
cutaneous functions, suppression of the perspiration, hemorrhoidal 
disease or venous hyperemia, especially in lymphatic individuals, 
the sulphur waters have special applicability. In France, the 
warm alkaline springs of Plombieres and those of Eaux Chaudes, 
in the Pyrenees, are famous in such cases. 

When menorrhagia is due to anaemia, atony of the uterus or 
granular ulceration of the cervix, the chalybeate waters, both 
internally and as baths, and injections, are called for ; but when 
the excessive flow is connected with venous stasis, hyperaamia of 
the liver, heart disease, emphysema of the lungs, abdominal tumors 
or the climacteric epoch, the diseutient alkaline springs, as Marien- 
bad, Carlsbad, etc., and the saline waters of Franzenbad, Tarasp, 
etc., will be more appropriate, and will render essential service. 

Against chronic parenchymatous metritis, with infarcts and 
exudations, cold local aud general douches are recommended, and 
the use of the alkaline-saline springs, Homburg, Ems, etc. 
Where chronic exudations are the most prominent symptom, 
real and prompt benefit is often obtained from sool baths, the 
iodine and bromine waters, and sulphur springs. The former 
should be preferred where there is a scrofulous diathesis present, 
the latter when there is a prominence of nervous erethism, or 
where the infarct follows a puerperal inflammation or deficient 
involution. Chalybeate waters in these cases are only appro- 
priate when marked ans&mia is to be combated, and sea bathing 
should not be advised as long as the exudation remains un- 
absorbed. 

Various waters containing iodine and bromine have been at 
times in repute for producing absorption of neoplasms in and 
around the uterus. They certainly do occasionally diminish the 
volumes of such growths, but their use is to be discountenanced 
when fever or much pain is present, or when the tumor is of 



BALNEO-THERAPY IN DISEASES OF WOMEN. 23 

rapid growth. Springs of repute in such cases are Kreuznach 
Halle, in Austria, Wildegg and Saxon, in Switzerland, and Cas- 
trocaro, in Italy, which last-mentioned has also a reputation for 
diminishing hypertrophied breasts and mammary tumors. 

Many waters are used with advantage in leucorrhoeal cases. 
AVliere simple anaemia is present, the iron waters are appropriate ; 
where the patient is scrofulous, those containing iodine and bro- 
mine, and the sool baths ; where the vaginal mucous membrane 
is much relaxed, local douches of carbonic acid gas, and baths 
of pine tree needles, are adopted with good results. Waters con- 
taining chloride of sodium have also a just reputation in such 
cases. 

Sterility, when, as is not unfrequently the case, it depends on 
general debility and anaemia, may at times be removed by the 
iron springs ; and in other instances, probably where the sterility 
depends on a hyperacidity of the vaginal secretion, or similar 
constitutional cause, an alterative alkaline water often acts with 
satisfactory promptness. In Germany, the alkaline waters of 
Ems, and those of Wolkenstein, in Saxony, are famous for facili- 
tating conception. The same is true of the warm alkaline springs 
of Plombieres, in France, and those of Bormio and Krumbach, 
and of Citara, on the island of Ischia, etc. The last-mentioned 
is peculiarly tonic aud stimulating, suitable for pale and weakly 
women. 

Some obstinate cases of pruritus vaginae, especially those occur- 
ring about the change of life, have been greatly relieved by warm 
alkaline and sulphur waters, used both internally and locally. 

It is needless to say that the employment of these balneological 
means does not exclude treatment by the usual methods. It is 
only maintained that in many cases where the latter, used alone, 
fail to restore health, it can be recovered by the aid of the 
methods just rehearsed. 



24 GYNECOLOGICAL THEEAPEUTICS. 



PLAN FOR A GYNECOLOGICAL EXAMINATION. • 

A compact schedule for " case-taking" in gynecology was pub- 
lished in the Edinburgh Medical Journal, February, 1880, by 
Prof. A. R. Simpson. It is, in some respects, an improvement 
on any previously suggested, and for the convenience of practi- 
tioners we here append it : 

DISEASE. 

ANAMNESIS. 

1. Name ; Age ; Occupation ; Residence ; Married, Single, or "Widow ; 

Date or Admission. 

2. Complaint and Duration of Illness. 

3. General History or — (a) Present Attack ; (6) Previous Health; (c) Dia- 

thesis ; (d) Social Condition and Habits ; (e) Family Health. 

4. Sexual History. 

(1) Menstruation — 

A. Normal — ((a) Date of Commencement ; (6) Type; (c) Dura- 

tion ; (d) Quantity ; (e) Date of Disappearance. 

B. Morbid — (a) Amenorrhoea ; (6) Menorrhagia ; (c) Dysmenor- 

rhoea. 

(2) Intermenstrual Discharge — (a) Character; (b) Quantity. 

(3) Pareunia. 

(4) Pregnancies — (a) Number ; (b) Dates of First and Last ; (e) Abor- 

tions; (d) Character of Labors; (e) Puerperia; (/) Lactations. 

5. Local Functional Disturbances of — (a) Bladder ; (b) Eectum ; 

(c) Pelvic Nerves and Muscles. 

6. General Functional Derangements of — (a) Nervous System ; (b) Ins- 

piratory System ; (c) Circulatory System ; (d) Digestive System ; 
(e) Emunctories. 

PHYSICAL EXAMINATION. 

1. General Appearance and Configuration. 

2. Mammj;. 

3. Abdomen — (a) Inspection ; (b) Palpation ; (c) Percussion ; (d) Ausculta- 

tion ; (e) Mensuration. 

4. External Pudenda. 

5. Per Vaginam — (a) Orifice; (6) "Walls and Cavity; (c) Roof; (d) Os and 

Cervix Uteri. 



PLAN FOR A GYNECOLOGICAL EXAMINATION. 25 

6. Combined Examination— (Abdotnino- Vaginal, Kecto- Vaginal, Abdo- 

niino-Rectal, Abdomino-Recto- Vaginal, Abdomino-Vesico- Vaginal)— 

(1) Uterus— (a) Size; (b) Shape; (c) Consistence; (d) Sensitiveness; 

(e) Position ; (/) Mobility ; (g) Relations. 

(2) Fallopian Tubes. 

(3) Ovaries — (a) Size ; (6) Situation ; (c) Sensitiveness. 

(4) Peritoneum and Cellular Tissue. 

(5) Bladder. (6) Rectum. (7) Pelvic Bones. 

7. Use of — (a) Speculum ; (b) Volsella ; (c) Sound ; (d) Curette ; (e) Aspira- 

tor v Needle ; (/) Tent or Dilator. 

8. Physical Changes in — (a) Nervous, (6) Respiratory, (c) Circulatory, (d) 

Digestive, (e) Emunctory Organs. 

DIAGNOSIS. 

PROGNOSIS. 

TREATMENT. 

PROGRESS AND TERMINATION 

Every case will not, of course, demand inquiry regarding 
every point registered in the several paragraphs. But, on the 
other hand, any case that comes before us may demand inquiry 
as to any of these points. 



CHAPTER I. 



DISEASES OF THE OVARIES, DISORDERS OF 
MENSTRUATION AND GENERAL DISEASES. 



Synopsis of Diagnostic Points — Ovaritis, Acute and Chronic 
{Ovarian Neuralgia, etc.) — Ovarian Tumors — Amenorrhea — 
Dysm enorrhcea — Menorrhagia and Metrorrhagia — Hysteria — 
Chlorosis and Anosmia — The Change of Life, or Climacteric 
Epoch. 

SYNOPSIS OF DIAGNOSTIC POINTS. 

OVAEITIS. 

The principal diseases of the ovaries are acute, subacute, and 
chronic ovaritis or oophoritis, and ovarian tumors. 

The following are the distinctions between the two forms of 
inflammation of the organ. 



Acute Ovaritis. 

Preceded by sudden suppres- 
sion of menstruation, gonorrhoea, 
pelvic peritonitis or external vio- 
lence. 

Fever, perhaps chill; severe 
pain in one or both iliac fossae. 
Great sensitiveness over the 
ovary, which may sometimes 
be felt as a round ball. 



Abscess or resolution in four 
to six days. 



The disease is rare. 



Chronic Ovaritis. 

Preceded by displacements of 
uterus, irregular menstruation, 
or neglect of precautions at 
menstrual epoch. 

Fixed pain over one or both 
ovaries, dysmenorrhea and hys- 
teria, pain in rectum and down 
thighs, worse after defecation, 
leucorrhcea, sometimes sterility 
and dyspareunia. 



Chronic, and not amenable to 



treatment. 



The disease is quite common. 



27 



28 DISEASES OP THE OVARIES. 

In the subacute form, by the recto-vaginal touch, we may 
grasp with the two fingers a smooth, roundish body, as large as 
a cherry, producing exquisite pain. This sign is characteristic of 
subacute oophoritis, for neither simple morbid congestion of the 
ovary, nor oophoralgia, nor retro-uterine hematocele, nor metritis, 
nor lymphadenitis, nor perimetric phlegmon, will give the phe- 
nomenon of pain so well marked and so precisely localized. 

It should be remembered that gonorrheal infection is an occa- 
sional cause of acute ovaritis, in which case specific treatment is 
demanded after the first symptoms have abated. 

In chronic ovaritis Atthill has observed that persistent 
vomiting is a prominent symptom. 

In a lecture reported in the London Medical Times and Gazette, 
Dr. J. Matthews Duncan states that occasionally this disease 
is seen as a consequence of fever, especially typhoid, cholera, 
and rheumatism ; in close connection with these diseases, it is 
very frequently a result of the use of alcoholic liquors, even when 
these are not taken to excess ; and this view of the causation of 
the disease is in the most gratifying manner frequently corrobo- 
rated, if not proved, by the cure which follows upon the adop- 
tion of strictly temperate living. A great mass of cases occur 
as a consequence of recent marriage, suppression of menstrua- 
tion, abortion, and delivery at the full time, when there is no 
evidence of blood-poisoning. 

OVARIAN TUMORS. 

The diagnosis of these tumors is often of the utmost difficulty. 
In the first place, pelvic tumors generally are simulated by preg- 
nancy, ascites, obesity, intestinal and vesical distention, and 
similar conditions. When a tumor is actually present, it may 
arise from other sub-peritoneal tissues as well as from the ovary. 
And when from the ovary, it may be either malignant or be- 
nign. 

Professor Kgeberle, of Strasburg, lays down the following 
general rules : 

In subperitoneal serous cysts, there is no loss of flesh. The 



SYNOPSIS OF DIAGNOSTIC POINTS. 29 

tumor, unilocular, presents a very manifest fluctuation ; its walls 
are thin ; its development slow, though at times rapid enough ; 
it sometimes attains a considerable size without becoming adhe- 
rent, to neighboring organs; sometimes it is small and very 
adherent. 

In cysts of the ovary, wasting is pronounced. The tumor, 
whether uni or multilocular, often presents a limited fluctua- 
tion ; its walls are occasionally thin, occasionally more or less 
thick and resistant, hard nodulated ; its development is ordin- 
arily rapid, sometimes slow ; lastly, it is adherent whenever the 
volume is at all considerable. 

A more positive method is by aspiration and examining the 
contained fluid. This diagnosis rests principally on the presence 
or absence of albumen, metalbumen, and paralbumen. Parova- 
rian cysts, or those of the broad ligament, contain a very fluid 
liquid, generally colorless and limpid as water, sometimes quite 
salt, but generally not containing any albuminous material ; 
when it does contain albumen, it is the paralbumen that is pre- 
cipitated by nitric acid, but the precipitate redissolves in acetic 
acid. 

Cysts of the Fallopian tube contain only albumen, and no 
paralbumen ; the precipitate produced by nitric acid is increased 
by acetic acid. 

Ovarian cysts furnish a liquid charged with albumen, metalbu- 
men, and especially paralbumen, giving a precipitate soluble in 
nitric acid. 

Well marked, these reactions are conclusive ; but there are 
exceptional cases where they are but feebly present. 

All doubt is removed, however, and we have to do with an 
ovarian cyst, when puncture gives exit to a glutinous fluid, some- 
times entirely uncoagulable by heat and nitric acid, rarely limpid, 
containing only traces of albumen (colloid cysts\, or a fatty liquid 
containing in suspension mucus and epidermic detritus or hair 
(dermoid cysts.) Lastly, examined by the microscope, the fluid 
of ovarian cysts contains granular globules, yellowish, 0.003 



30 DISEASES OF THE OVARIES. 

millimetres to 0.060 millimetres in diameter, the envelope being 
rendered more apparent by acetic or phosphoric acid. 

Mr. Spexcer Wells remarks that in ascites the stomach 
and intestines, containing air, float on the surface of the fluid, 
and, therefore, the highest points of the tumor, the patient lying 
on her back, give out a clear sound on percussion. If, however, 
the fluid be contained in a cyst, the stomach and intestines are 
pushed aside, as the tumor rises in the abdomen, and lie in the 
epigastric and two lumbar regions. Hence, the highest points 
of an ovarian tumor emit a dull sound when percussed, and the 
epigastric and lumbar ones give a clear sound. By applying 
these general rules in any ordinary case, a few seconds will 
enable a surgeon to clear up all doubt. 

Atlee says mobility diminishes as size increases, there is free- 
dom from constitutional symptoms, the emaciation is most striking 
about the face, neck, shoulders and arms, the expression of coun- 
tenance is anxious, careworn, the features attenuated, the com- 
plexion pale. An important point in the position of the tumor 
in relation to the viscera; it is usually in front, and gradually 
crowds them backward, upward, and to the sides. There is a 
dull percussion sound over the space occupied by the tumor. 
Fluctuation can be recognized only in the tumor. The form of 
the abdomen is rarely uniform. 

As a general rule, according to Dr. T. M. Drysdale, ovarian 
fluids have an animal odor; they are rarely clear, usually cloudy, 
and frequently opaque ; in color they vary from that of white of 
egg or clear starch, to shades of yellow, red, green, or dark choco- 
late, or even inky black ; in consistence, they may be almost like 
water, or thin syrup, mucilage, oil, or molasses, or ropy, or jelly- 
like; but they always are sticky and viscid, and generally feel 
slimy. A sediment rarely fails to form after a few hours ; this 
is viscid, and often like pus. Reaction generally alkaline. 
Chemically they consist of albumen, fats, extractives and salts. 
Notably they contain an excessive amount of solid matter, often 
one-tenth of the whole weight of fluid. They never contain 
fibrin, unless hemorrhage has occurred into the cyst, or it has 



SYNOPSIS OF DIAGNOSTIC POINTS. 



31 



been inflamed. Microscopically they usually display free granu- 
lar matter, oil globules, epithelial cells, crystals of cholesterine, 
etc., but no matter what other cells may be present or absent, the 
cell which is almost invariably found in ovarian fluid is the granu- 
lar cell. This is generally round or may be slightly oval, deli- 
cate, transparent, contains a number of fine granules, but no 
nucleus. The granules are well defined. Acetic acid maJ:es 
them more distinct. Either renders them nearly transparent. 
Other cells, on the addition of the acid, increase in size, become 
very transparent and exhibit nuclei. 

The differential diagnosis between ovarial cysts and ascites, is 
represented as follows by Prof. Eobert Olshausen, (Hand- 
buch der Frauenkrankheiten, edited by Billroth, part VI.) : 



Ovarial Cysts. 
Of slow growth. 



CEdema of the lower extremi- 
ties rare and late. General 
oedema almost never. 

Abdomen barrel-shaped ; ribs 
thrown outward. Anteropos- 
terior diameter greater. Great- 
est periphery below the navel. 

Change of position does not 
affect the form of the trunk. 

Percussion of the most ele- 
vated portion (near the navel) 
hollow. Change of position 
does not alter percussion sound. 



Fluctuation -limited to the 
region of the hollow sound. 

Uterus often elevated or 
pushed back in the hollow of 



Ascites. 
Rapid development; 



sonie- 
; sometimes 
liver or kid- 



times with fever 
concominant heart, 
ney disease. 

CEdema of the lower extremi- 
ties early; often general anas- 
arca. 

Abdomen spherical ; ribs nor- 
mal ; the body, in lying, more 
broad than high ; greatest peri- 
phery at the navel. 

Form of trunk differs when 
standing and when lying on the 
side. 

In lying on the back, percus- 
sion of most elevated portion 
sonorous. Change of position 
always brings the hollowest 
sound to the most elevated por- 
tion of the trunk. 

Fluctuation marked, easily 
produced, most prominent at 
most elevated points. 

Uterus often descends, even 



32 



DISEASES OF THE OVARIES. 



the sacrum; diminished in mo- ' to prolapse; unusually mov- 
bility. able. 



Contained fluid thickish, mu- 
cous; of almost any tint; spec, 
grav. 1015-1030; very rarely 
coagulable; contains epithelial, 
cylindrical cells; often choles- 
terin, rarely pus corpuscles. 



Fluid thin, clear; yellowish 
or greenish; sometimes tinged 
with blood; spec. grav. 1005- 
1015; sometimes coagulates 
after standing. Contains white 
blood corpuscles; seldom or 
never cylindrical epithelium or 
cholesterin. 



AMEXOKRHCEA. 

Amenorrhcea may be primative or acquired. In the first form 
menstruation has never taken place, or if it has occurred at all, 
the discharge has always been scanty, or has appeared at pro- 
longed intervals, or both. In the second form menstruation has 
taken place regularly and healthily, and has afterwards become 
suppressed. 

The following table represents the various forms of this affec- 
tion, their causes and pathological significance : 



Menstruation 
absent 
(emansio 
mensium). 



Menstruation 
scanty. 

Menstruation 
irregular 
and gen- 
e r a 1 1 v 
scanty. 



PRIMITIVE AMENORRHEA. 



f Uterus undeveloped or absent ; 
Ovaries well or ill-developed or absent. 

f Anaemia. 
Uterus well de- | £h™nic dise . ase ' ,., 
veloped, but ! Bad h ^ lenlc C0 * dltl0Ils - 



No formation of 
decidua. 



inactive. 
Ovaries, well -j 
developed. 



Emotional shocks. 
Physical shocks. 
Acute diseases. 
Change of residence. 
Exposure. 
Bathing. 
I Plethora. (?) 



| Scanty forma- 

■{ tion of de- 
cidua. 

I 

f Irregular and f ^ 
generally 

\ scanty forma- 
tion of de- 

|^ cidua. 



Uterus small. 

Ovaries well or ill developed. 
Uterus well de- f Anaemia, 
veloped. \ Bad health. 

terus usually 

small, but! Anaemia. 

may be well- j Bad health. 

developed. 



L 



SYNOPSIS OF DIAGNOSTIC POINTS. 



33 



ACQUIRED OE SECONDARY AMENORRHEA. 







- 


' Anremia. 

Chronic disease of lung, 
liver, kidney, ovaries, 
uterus, or gastrointes- 
tinal canal. 


Menstruation 




Uterus and 


Bad hygiene. 


a b s e -n t 

(suppr es- 1 


No decidua 
formed. 


ovaries well -j 
formed. 


Shocks, physical or emo- 
tional. 


s i o men- 




Acute diseases. 


sium.) 






Blood -taint. 

Exposure. 

Bathing. 

Change of residence. 






Over-involution after labor. 




. 


_ Early menopause 





In place of the discharge of blood, there may be a leucorrhcea, 
more or less profuse. 

It should never be forgotten that in uot infrequent instances 
amenorrhoea, supervening apparently without cause, is the first 
sign of phthisis, and in all such cases should arouse the most 
active attention of the physician. Some writers hold that in 
these cases the amenorrhoea is not so much the sign as the 
exciting cause of the tuberculous change. 

3 



34 



DISEASES OF THE OVARIES. 
DYSMENORRHEA. 



The forms and causes of dysmenorrhea are defined by Prof. 
T. G. Thomas, in accordance with the following table : 



From. 



ISeuralgia. 



Dysmenorrhea. 



Congestive or In- 
flammatory 
Dysmenorrhea. 

Obstructive Dys- 
menorrhoea. 



Membranous 
Dvsmenorrhoea. 



Ovarian Dysmen- 
orrhea. 



Symptoms. 



Pain usually sharp and fixed. 



No expulsive pains ; flow steady ; 
no clots ; no obstruction ; occurs 
gradually ; is habitual ; no en- 
dometritis. 

Pain severe, sudden ; discharge 
lessens or ceases. General py- 
rexial signs, and inflammatory 
constitutional disturbance. 
Pain sudden and accompanied 
with an expulsive effort after 
menstruation has commenced 
some hours ("uterine colic"); 
recurrence of these symptoms. 
Discoverable obstruction. 
Pains steady, becoming violent 
and expulsive; passage of 
membrane at each period ; as 
sequela?, endometritis and 
menorrhagia. Very rare. 

Pain, dull and sickening, usually 
precedes the flow several days, 
and lessens when it comes on. 
Breasts painful or tender. 
" Submammary pain." " In- 
termenstrual pain," occurring 
between the epochs. Ovaries 
often enlarged and tender. Pain 
habitual at each ejDoch ; often 
shoots down the thigh. 



The neuralgic diathe- 
sis ; plethora or chlo- 
rosis ; malaria ; the- 
umatoria : onanism. 



Exposure to cold and 
wet ; tumors ; mental 
disturbance, endo- 
metritis, etc. 

Contraction of cervix ; 
uterine flexion ; pol- 
ypus or fibroid ; ob- 
turator hymen. 



Early abortions ; diph- 
thertic endometritis. 



Ovaritis; excessive 
nervous hyp era? s- 
thesia. 



Barnes says a characteristic sign of ovarian congestion is that 
the body of the uterus is drawn toward the affected ovary. 

MENORRHAGIA AND METRORRHAGIA. 



By menorrhagia is meant an excessive flow of blood at the 
menstrual period ; by metrorrhagia, a flow of blood between the 
menstrual epochs. 



SYNOPSIS OF DIGAGNOSTTC POINTS. 35 

Neither of these forms of trouble can be called a disease, as 
they are solely symptoms of several kinds of uterine affection. 
In order to diagnose the cause, and thus obtain the indications 
for treatment, a careful examination becomes necessary. In most 
instances, it is the result of general debility, as from protracted 
nursing. Locally, it may be caused by the presence of tumors, 
as polypi, etc., affections of the os and cervix, congestion of the 
womb or ovaries, subinvolution of the womb, or inversion of 
that organ. 

Debility as a cause is recognized by the usual symptoms, and 
the accompanying predisposing circumstances, as lactation, anx- 
iety, exhausting labor, etc. 

Polypi, when low down, are easily recognized by the finger, 
though the speculum may be used to confirm the diagnosis. In 
these cases there is leucorrhoea, more or less bloody, and at inter- 
vals discharges of pure blood, without relation to the period of 
menstruation. When a polypus is not found pendent in the va- 
gina, the presence of these growths may be suspected above, as 
in the canal of the neck, or even within the uterus itself, and 
attached to the fundus. The absence of other causes of the 
hemorrhage would demand dilatation of the organ if necessary, 
and a careful search for these excrescences. 

Subinvolution only occurs in women who have been pregnant. 
Here, the womb, after delivery has been accomplished, fails to 
return to its proper condition. The diagnosis is readily made 
by examination. The uterus is much larger than natural, the os 
soft and patulous ; there are pains in the back, irritability of the 
bladder, frequent micturition, with tenesmic efforts, and generally 
very profuse leucorrhoea. These may end in erosion of the os 
and cervix, and added to these we may have congestion of the 
lips of the womb. 

Again, hemorrhage may be due to the presence of a portion 
of the placenta, which is frequently the case after an abortion. 
This might be suspected from the history of the case, and the 
diagnosis fully made by an exploration with the sound, when the 



v] 



36 DISEASES OF THE OYAEIES. 

foreign body is detected. In such cases there is generally a cer- 
tain amount of odor, as of a decaying body, in the cavity. 

In the unmarried, a spongy state of the cervix is generally a 
cause; this is shown by eversion Of the lips, and granulations on 
the surface. 

Malignant disease as a cause is detected by the general history ; 
there has been more or less pain, often lancinating, in the lower 
part of the abdomen, the back, around the hips, and extending 
down the thighs, which frequently seems to be much relieved after 
profuse hemorrhage has occurred. This hemorrhage would occur 
from a slight exertion, or after coitus. Examination shows in 
advanced cases fixation of the uterus, hardness and irregularity 
of the parts. In early cases, these symptoms all exist, but to a 
less extent. 

CHLOROSIS AXD AJJLEMTA. 

These two diseases, though not strictly synonymous, m*ay, from 
their great resemblance, be treated of as one. A marked fea- 
ture is amenorrhea, or imperfect menstruation. The complex- 
ion is pale, or of a greenish yellow. The patient is listless, loses 
appetite, or only desires dainties, generally craves acids, or may 
even prefer articles of an injurious or loathsome nature; she is 
irritable, hysterical, suffers with headache, which is sure to come 
on after the slightest excitement or exertion. The poverty of 
the blood is shown by cold extremities, swelled feet and hands, 
pufSness of the face, dark rings around the eyes, and blowing 
sound of the heart. Though not always present, yet, in many 
instances, there are vague neuralgic stitches in the breasts, the 
head, the sacral region. In rare cases, after the disease has con- 
tinued awhile, a slow fever sets in, which may lead to an error 
in diagnosis. 

THE CHAXGE OF LIFE. 

This period, known as the climacteric or menopause, varies 
greatly as to the time of its appearance. The woman menstru- 
ates for about thirty-five years, and then occurs a marked change, 
which may be sudden, or may slowly steal upon her. Most com- 



SYNOPSIS OF DIAGNOSTIC POINTS. 37 

raonly this is attended by a variety of troubles, which to a greater 
or less extent affect the general health. A most frequent symp- 
tom is irregularity of the menstrual function. It ceases, per- 
haps, for months, and as suddenly re-appears. Or the flow be- 
comes alarmingly profuse, exhausting the patient, draining her. 
"With this may be associated hemorrhages from the nose, from 
the bowels, profuse leucorrhcea, and brain symptoms as of con- 
gestion, vertigo, frequent syncope, epileptic or apoplectic seizures. 
Barnes regards the headache as peculiar, chiefly occipital, in- 
volving the nucha and spinal cord. The mind is affected. 
There are irritability, loss of memory, despondency, even partial 
insanity, but all of which are generally acknowledged by the 
patient, and she regrets her want of self-control. 

The appetite is capricious or lost, generally the bowels are ob- 
stinately costive, fat begins to accumulate, and these symptoms 
often give rise to the belief that the woman is pregnant, which 
is speedily dispelled by the proper examination. The liver and 
kidneys, in fact nearly every organ, are liable to become affected 
and to add to the general discomfort. 



38 DISEASES OF THE OVARIES. 

OVARITIS, ACUTE, SUBACUTE AND CHRONIC. 

DR. L. DE SINETY, OF PARIS. 

This author believes that true ovaritis, that is, an inflamma- 
tion limited to the ovary, is excessively rare. Generally, what 
is so called is pelvi-peritouitis and lymphangitis. Patients 
should keep the bed, aud take warm baths and continued vagi- 
nal injections. Local blood-letting and leeches to the abdomen 
are appropriate. Against the pain, chloral, chloroform and 
morphine, hypodermically, are required. The rectum should be 
emptied by enemas, the bladder by the catheter. If the tumor 
becomes fluctuating and points, it should be aspirated. 

The chronic form is nearly always associated with anaemia, 
and will be benefited by iron and quinine. Preparations of 
iodine will also be found of good service ; as : 

1. R. Tincture iodinii, gtt. iij. 

Aquae, § j-ij. M. 

This amount three times a day. 

This author doubts the existence of the alleged blenorrhagic, 
syphilitic, and rheumatismal forms of ovaritis, as also that it 
arises fiom onanism, excessive venery or menstrual suppression. 

PROF. ROBERT OLSHAUSE^, OF HALLE. 1 

Though opinions differ on the subject, this writer is of opinion 
that chronic oophoritis is by no means rare, both among married 
and unmarried women of youthful years. Its cause is often ex- 
cessive cohabitation or onanism ; but it may follow an acute at- 
tack, the result of suppressed menses, metritis, etc. 

All cohabitation, as well as fatigue, much walking or standing 
are to be forbidden. Local abstraction of blood from the uterus 

1. Handbuch der Frauenkrankheiten. Edited by Billroth, part VI. 



OVARITIS, ACUTE, SUBACUTE AND CHRONIC. 39 

is occasionally useful. The most efficient internal remedies are 
iodide of potash and the preparations of gold. The latter was 
much lauded by Noeggerath, who claimed that in twenty-five 
cases he effected reduction of the swelling in from six to eight 
weeks by administering gr. ij. daily. Olshausen has not had 
such good results, but in some cases had witnessed decided 
benefit. 

Anodynes, at the menstrual period, can often not be dispensed 
with, and blisters to the abdomen are at times useful. A local 
measure of unquestionable benefit is a moderate-sized soft rubber 
ring pessary. This fixes the uterus, and prevents dragging. 
When, however, there is prolapse of the ovaries it cannot be 
worn. 

As a last resort the removal of the ovary by the operation 
of spaying has to be considered. 

PROF. J. MATTHEWS DUNCAN, LONDON. 1 

The writer observes that a great many cases of the chronic 
forms of ovaritis — which he esteems a very common disease — 
are almost incurable. When they resist a properly-conducted 
treatment, it is wisest to give up the attempt at cure. 

In every case rest is demanded. In severer cases the patient 
should keep her bed ; marital relations should be suspended, and 
especially at the menstrual period should repose be enjoined. 
In many cases, leeches applied to the neck of the womb or over 
the inguinal canal, are very valuable. Of medicines, the most 
to be relied upon are corrosive sublimate, iodide of potash, and 
bromide of potash. Blisters over the inguinal ring are frequently 
of decided advantage in chronic cases. Croton oil or antimonial 
liniment may be applied to the inguinal canal adjacent to the 
affected gland. 



In acute cases, entire rest is essential. When the attack is 

1. Lectures on Diseases of Women, 1880. 



40 DISEASES OF THE OVAEEES. 

owing to a chill, from exposure, leeches should be applied over 
the ovaries, followed by hot anodyne poultices. Hot turpentine 
stupes are also valuable. 

In chronic cases, cold affusions and hip baths are often useful. 
Sexual indulgence must be strictly limited. At the menstrual 
periods the patient should remain on the couch, and a stimulating 
nourishment be avoided. Between the "epochs moderate out- 
door exercise is valuable. Tartar-emetic ointment or other 
counter-irritants may be used over the ovary. To relieve pain 
the following pill is efficacious : 



2. R. . Pnlveris opii, gr. ss. 

Extracti cannabis indicas, gr. J. 

Canrphorse, gr. j. M. 

For one pill, night and morning. 



In severe ovario-uterine pain, this practitioner recommends 
placing a pledget of cotton-wool, soaked in laudanum, or acetate 
of morphia, near or upon the neck of the womb. This may be 
repeated daily or every other day. Two or three grains of mor- 
phia may be used at a time in this manner. 

"When the ovaries are congested or inflamed, the best method 
of treatment is to leech the womb. Four leeches may be applied 
to the cervix a day or two after the flow has ceased. The effect 
is usually well marked. Blisters and ointments to the hypogas- 
tric region only act on the ovaries indirectly, and even double 
the number of leeches mentioned, when applied over the ovary, 
do not produce so permanent an effect. 

In chronic and obstinate forms of ovario-uterine disease, silk 
setons applied above the pubes, as recommended by Hug-tier, 
deserve trial. 

For the pelvic and spinal pains of ovario-uterine disease, Dr. 
Tilt recommends rubbing the surface twice a day with one of 
the following ointments : 



41 



S. R. 


Linimenti belladonnse, 


5s9- 






Glycerinae amyli, 


*3J- 


M. 


4. R. 


Morphias acetatis, 


gr. x. 






Glycerinae, 


f. z ss. 






Otto rosar., 


gtt.j. 






Unguenti petrolei, 


IJ- 


M. 


5. R. 


Potassii iodidi, 


3J. 






Magnesiae, 


gr. v. 






Otto rosar., 


gtt.j- 






Aquae, 


|3j. 






Unguenti petrolei, 


3J- 


M 


y twice daily. 






6. R. 


Atropine sulpliatis, 


g r - ij- 






Morphias sulpliatis, 


gr. iv. 






Olei olivse, 


f.^j- 






Olei lavandulae, 


gtt. X. 






Unguenti hydrargyri fortis, 


gj- 


M. 



A piece about the size of a small walnut is to be rubbed in morning and 
evening, over the sensitive ovary. 



Ovarian Neuralgia. — This writer maintains that in various 
instances we meet with true ovarian neuralgia, independent of 
any local lesion, and more remediable by constitutional than by 
local treatment. He identifies it with the ovarian irritation of 
Dr. Churchill. His prescription for such cases is : 

7. R. Ammonias muriatis, gij. 

Tincturse aconiti, f. ^ ij. 

Syrupi aurantii corticis, f.^ viij. M. 

A teaspoonful thrice daily in the treatment of ovarian neuralgia. 

Dr. Curran states that this combination has almost a magi- 
cal influence in many cases. He reports (Medical Press and 
Circular, August 9th, 1868,) six cases in which various seda- 
tives and anodynes had been tried in vain. In all he found that 
before the above mixture was finished by the patient, the pains 
had entirely ceased. 

Dr. T. J. Newman, of Chicago, confirms the usefulness of 
this mixture, and records (in the Chicago Medical Examiner, for 



42 DISEASES OF THE OVARIES. 

November, 1869,) three cases of neuralgia of the ovaries treated 
by it with success, after the failure of other remedies. 

In the same painful complaint, Dr. Boberts Bartholow 
has obtained excellent results from the following recipe : 



8. R • Extract! belladonna?, gr. iv. 

Extracti stramonii, gr. v. 

Extracti hyoscyaini, gr. v. 

Quinise sulphatis, ^ij. M. 

Make twenty pills. One three times a day, in ovarian neuralgia and neu- 
ralgic dysmenorrhoea. 



DR. J. MILNER FOTHERGILL, OF LONDON. 

Ovarian Dyspepsia. — This writer has pointed out that a fre- 
quent complication and often the most prominent symptom of sub- 
acute ovaritis is a form of gastric atony which he calls " ovarian 
dyspepsia." (American Journal of Obstetrics, January, 1878.) 
For the treatment of such cases he recommends as the great 
therapeutic agent, the bromide of potassium. 

9. R . Magnesia? sulphatis, % j. 

Potassii bromidi, 9;. 

Infusi gentianse, f-.^j- M. 

This amount three times a day, with an aloes and myrrh pill at bed-time, 
if necessary. 

A blister should be applied over the tender ovary. 

For the vaginal loss, injections of astringents in solutions by 
means of a Higginson's syringe, or the small india-rubber ball 
and tube used to give babies enemata (much better in every way 
than a glass syringe), must be used twice a day, with hip-baths 
daily, if the patient's condition will admit of it. This is far 
from unimportant. When there is nienorrhagia, quietude and 
the avoidance of all warm drinks and food during the flow are 
desirable. For the imperfect digestion, light and easily digest- 
ible food, milk, if necessary, combined with an alkali, or beef 
tea with a little cream in it, or custard, are indicated. Such food 
should be given at short intervals, and small quantities at once. 



OVARITIS, ACUTE, SUBACUTE AND CHRONIC. 43 

The irritable stomach will often retain small quantities of food 
when larger amounts are at once rejected. 

LAWSON TAIT, F. R. C. S., BIRMINGHAM. 

This writer (Diseases of Women, 1879,) divides inflammatory 
affections of the ovaries into (1) ovarian hyperemia, (2) acute 
ovaritis, (3) chronic ovaritis. 

Ovarian Hyperemia. — This is frequently met with in young 
girls and in young married women with vigorous husbands, and 
in prostitutes of tender age. The patient should rest in a prone 
position for a few days before, during, and after the menstrual 
period ; a counter-irritant should be placed over the ovarian re- 
gion just before the flow is expected ; and she should take efi^got 
before and during the period, and the salts of potassium contin- 
uously during the intermenstrual time. His favorite formula is : 

10. R . Ergotinse (Bonjean), gr. ss. 

Lupulinse, q. s. M. 

For one pill. 

In addition to this, between the epochs, 
\ 

11. R. Potassii bromidi, gr. v-x. 
For one dose, night and morning, after meals. 

All cases of ovarian hyperemia which Mr. Tait has met 
with at puberty, have yielded to this treatment, and most of 
those of a later age. 

Acute and Chronic Ovaritis. — No time can be laid down where 
ovarian hyperemia passes into ovaritis, nor between the acute 
and chronic forms of the latter. The treatment should consist 
of local and systemic rest, and the administration of ergot. 
Locally, counter-irritation in the inguinal region, with linimen- 
tum iodi every morning until the spot is sore, and this repeated 
frequently, will nearly always do good. Bromide of potassium 
may be combined with the ergot. Arsenic and cod-liver oil are 
also useful, and some cases will yield to large doses of quinine, 
when everything else has failed. 



44 DISEASES OF THE OVAEIES. 

KESUME OF EEMEDIES. 

Ammonice Murias is often efficient in ovarian neuralgia. 
(F. 7.) 

Antimonii et Potassi Tartras. Counter-irritation by means of 
tartar emetic ointment is of service in subacute ovaritis. 

Atropia, hypodermically, tJoVo" grain in ovarian neuralgia. 
Belladonna in plaster is often of service. 

Brominium. Barnes says that this agent seems to possess a 
specific power in diminishing ovarian irritation. 

Camphora is very serviceable in ovarian pain. (F. 2.) 

Hydrargyri Unguentum. Dr. E. J. Tilt, of London, recom- 
mends in subacute ovaritis : 

12. R. Unguenti hydrargyri, gij. 

Extracti belladonnas, £j. 

Cera?, Jpj. 

Adipis, Jj. M. 

Warm water enemata, and gentle aperients (castor oil), should accompany 
the treatment. 

Iodinium. Painting the sensitive regions with tincture of iodine 
is a useful means of counter-irritation. 

Opium. Vaginal suppositories of opium gr. ij., made up with 
paraffin, frequently give great relief. Aran was ac- 
customed to pour two drachms of laudanum daily or 
every other day, through a speculum, on and into the 
cervix. 

*Potassii Bromidum. This agent is asserted to possess almost 
specific powers in reducing ovarian irritation, and pain, 
nymphomania, etc. (F. 9.) 

Potassii iodidum is of decided value. (F.5 and p. 39.) 

Potassa cum Calce. In chronic ovaritis, Barnes recommends as 
a means of derivation, setting up a small issue or 
eschar on the vaginal portion of the uterus with this 
agent. 

Terebinthince Oleum, used in the form of hot epithems, is fre- 
quently available. 

Veratria. Dr. L. Atthill has seen great relief from the local 
application of equal parts of the ointment of veratria 
and iodide of potassium. 



OVARIAN TUMOES. 45 

GENERAL METHODS. 

Blisters over the ovarian region are frequently of service in the 

j subacute forms. 

Enemata. "Warm water enemata, retained as long as possible, 

are often of great benefit. 
Ice applied in a bag to the painful spot, is said by Dr. Tilt to 

relieve the pain of acute ovaritis. 
Leeches are a very valuable means of relief. (See p. 40.) 
Pessaries. A light pessary, to support the womb and keep the 

ovaries in their normal position, will often prove of 

decided advantage. 
Ovariotomy. As a last resource in severe ovaritis, the organs 

may be removed by Battey's operation. 



OVARIAN TUMORS 

The medical treatment of tumors of the ovaries embraces : 

Internal medication. 

Injections into the sac. 

Electrolysis. 
Internal Medication. — It has been believed by some practition- 
ers that a prolonged use of muriate of ammonia has led to atro- 
phy, absorption and disappearance of certain benign ovarian 
tumors. Two such cases are recorded at length by Dr. E. H. 
W. Hunter, in the Trans, of the Georgia State Med. Soc, 
1877. He gave gr. xx. of the muriate, four times daily. In 
ovarian dropsy, the free use of chlorate of potassium is said to 
have resulted in marked diminution of the contents. 

PROF. E. R. PEASLEE, M. D., NEW YORK, 

Believed that, in several instances, the growth of ovarian cysts 
had been checked by the application into the vagina, of iodide 
of lead. The ointment may be smeared on a cotton tampon, and 



46 DISEASES OF THE OVARIES. 

introduced from time to time. Care must be exercised that too 
great irritation is not excited. 

Injections into the Sac. — The substance usually employed for 
this purpose is iodine. Some surgeons use the pure tincture. 
Dr. Boinet, of Paris, employs : 

13. R. Tinct. iodinii,_ f-Jiij. 

Potassii iodidi, gj. 

Acidi tannici, 5 ss. 

Aquse destillate, f . ^ iij . M. 

He injects the whole of this amount, brings it in contact with 
the entire surface of the sac by gentle agitation, and then with- 
draws it. 

Prof. T. Gaillard Thomas recommends as the best proce- 
dure to empty the sac by the aspirator, and without withdrawing 
the needle, fill it with tincture of iodine, and in ten minutes 
draw it off. He would confine this plan of treatment only to a 
late period, in cysts of moderate size, with few compartments, 
and containing a fluid which is not very viscous. 

Electrolysis. — Within the last few years, great attention has 
been given, especially in Germany, to the dispersion of ovarian 
tumors by electrolysis, and it was at one time confidently an- 
nounced that this plan would supersede ovariotomy. 

Further observations show that while in many instances elec- 
tricity, properly applied, will reduce the tumors very materially, 
the effect of the agent is temporary, and it is very doubtful 
whether any permanent and real benefit accrues from the proce- 
dure. In Vienna, the electrolytic treatment has been carefully 
and repeatedly tested, and it is now wholly neglected as of no 
avail. (See Am. Jour, of Obstetrics, Oct., 1878.) 



In a report to the Amer. Med. Ass'n, in 1879, says it is danger- 
ous to operate on a person suffering with albuminuria. He re- 
gards it as proved that the results obtained are due to the 
passage of a current, and not solely to puncture. With Dr. 



OVARIAN TUMORS. 47 

Kimball, he has operated on sixty-one cases. In one case, the 
fibroid was extracted from the vagina fifty-three days after the 
application. In a similar case there was a small, nodulated 
mobile fibro-m void attached at and incorporated with the fundus. 
The os was ulcerated, and the operation was advised to arrest 
the hemorrhage. A current was applied for seven minutes. Two 
months after, no tumor could be felt, and the os was healed. In 
one case, an electrode was applied per vaginam, and the cir- 
cuit was completed by a sponge electrode over the pubis, but 
with such alarming results that the procedure was shown not to 
be safe. It is best to confine the action of the current to the 
tumor, as it alone is in fault, and needs the whole force. This 
is effected by complete insulation of the needle in the healthy 
tissues. 

DR. L. DE SINETY 

The medical treatment of ovarian tumors should be directed 
rather to supporting the general system and relieving dyspeptic 
symptoms, than with the hope of dissipating the tumor. Mer- 
cury, iodide of potassium, compression, massage, thermal waters, 
electricity, electro-puncture, ergotin hypodermically, etc., have 
been employed, and occasionally diminution of the tumor or 
even its complete disappearance reported ; but the same means 
employed by others have not yielded any such beneficial results. 

The surgical measure are the only ones to be relied upon. 
These are — 

1. Puncture. 

2. Drainage. 

3. Ovariotomy. 

It should not be forgotten that occasionally a simple puncture 
will bring about a complete cure of an ovarian cyst (instances by 
Panas, Archives de Tocologie, 1875.) Usually the puncture is 
associated with an iodine injection, as : 

14. R. Aquse destillatse, f.^v-vij. 

Tincturse iodinii, £5 iij. 

Potassii iodidi, gj. M. 



48 DISEASES OF THE OVAKIES. 

Out of one hundred and thirty cases operated upon in this 
manner by Dr. Boinet there were sixty-four recoveries. But 
it only succeeds in unilocular tumors where the fluid contained 
is clear and limpid. 

Prof. Coukty, in 1866, reported a case which he believed he 
succeeded in curing by inunction of iodine, general tonic meas- 
ures, and especially the prolonged administration of gold oxide. 

The bromide of potassium in moderately large doses has been 
alleged by several writers to have had the effect of reducing 
and dispersing the tumor. 

When one considers the anatomy of most of these cysts, such 
claims cannot but appear groundless, as a dispersion of them by 
medical measures is hardly conceivable. Probably the tumors 
or enlargements which diminished under such medication were 
not ovarian cysts at all, but belonged to the products of chronic 
inflammation, dropsy, etc. 

The hygienic and dietetic treatment of such cases is of great 
importance. Nothing should be undertaken which will depress 
the physical forces, and everything should be avoided which will 
stimulate the irritability of the ovaries. The diet should be 
light, and digestion and assimilation favored by fresh air and 
exercise. During the menstrual period the patient should keep 
her bed, especially when the flow is profuse. Sexual excitement 
should be discountenanced and pregnancy positively warned 
against. 



AMENORRHEA 



M. D., LONDON. 



Referring to the classification of the forms of amenorrhoea 
already given (see page 32), this writer suggests the general line 
of treatment as follows (Lancet, May 26th, 1877): 

Menstruation is and always has been absent. The great ma- 



AMENORRHEA. 49 

jority of cases of this class which will comu under observation 
w r ill be young girls between sixteen and twenty years of age. 
Many of them will suffer from anaemia and disorders of the 
digestive organs. Such cases are instances of late or tardy evo- 
lution of the generative organs. The form and figure may be 
well developed, but the uterus grows slowly, and the treatment 
consists in waiting and adopting all means that favor its growth. 
There will, after all, remain a few in which the discharge will 
not make its appearance. In these it will be found that the 
uterus is small, and the best treatment is non-interference. 

Menstruation is scanty or irregular. If it be due to an unde- 
veloped condition of the uterus, and if it be accompanied by no 
pain, the general health being good, it requires no special treat- 
ment. General means which favor physical development, as 
exercise of all kinds, may be recommended. If the uterus have 
obtained its full size, there will, in almost all cases, be found a dis- 
ordered state of the general health. The most common condition 
is anaemia. In such cases the physician should regulate the 
bowels, for there is generally constipation, and give iron, iodine, 
salines; good diet, fresh air, and exercise in the open air, are 
essential. Exercises of all kinds are good — riding, walking, 
swimming, dancing. If the monthly molimen be present, em- 
menagogues may be prescribed, but they should never be admin- 
istered when indications of ovarian and uterine action are present. 
The medicines supposed to have a direct action in bringing on 
the menses are numerous, but few of them are of much or even 
of any value. The best are electricity, aloes, and the stimula- 
ting diuretics — nitrous ether, spirits of juniper, and oil of tur- 
pentine. Hot hip-baths for five or six nights in succession 
before the expected return of the molimen are useful. Guaia- 
cum, ergot of rye, oil of savin, cantharides, have proved suc- 
cessful in the hands of some. Dr. Atthill recommends the 
warm hip-bath for eight or ten evenings in succession before 
the expected time. 

Suppression of the menses. When the suppression has taken 
place suddenly during a menstrual flow, the patient should have 

4 



50 DISEASES OF THE OVAEIES. 

a hot bath, go into a warm bed, and take a dose of Dover's 
powder. A stimulating diuretic or a diaphoretic should be at 
the same time prescribed. Should fever, heat in the skin, vomit- 
ing, pain in the abdomen, and symptoms of local inflammation 
or of general peritonitis set in, they should be treated irrespec- 
tive of the suppression. If- the flow is not re-established, the 
case becomes one of chronic suppression. 

Chronic suppression. The general health should be attended 
to, and if menstrual molimina be present they should be encour- 
aged, and efforts made to establish the flow by the means already 
enumerated. If molimen be absent, we must limit our aid to 
the treatment of the general health. 

PROF. R. J. GRAVES, M. D., DUBLIN. 

This author observes, in his Clinical Lectures, that the perio- 
dicity of the function of menstruation can still be traced, even 
in cases where suppression has continued for a great length of 
time, by means of the menstrual molimina (pains in the loins, 
thighs, and hypogastric region, flushing, colicky pains of the 
abdomen, general feeling of malaise,) which occur at stated 
intervals; in endeavoring to bring on the discharge, therefore, 
we must be guided as to the time the attempt should be made, 
by an observance of the period at which these molimina occur. 
For a few days before that time, our efforts to produce a deter- 
mination of blood to the uterus may be judiciously employed; and 
if they fail, the attempt should be abandoned until a few days 
before the next menstrual period. Of course, however, the 
general constitutional treatment must be constantly persevered 
in; one of the chief means of bringing back this evacuation 
being the restoration of health to the natural standard. But all 
such remedies as pediluvia, stuping of the genitals, leeches to 
the inside of the thighs, near the labia, aloes and other stimula- 
tive purgatives, etc., should be only used at the times spoken of. 
To use them at any other period, either after the molimina have 
disappeared, or during the intervals between them, tends, in 



AMENORRHEA. 51 

most cases, still further to derange nature, by determining to the 
uterus at an unseasonable time, when there is no natural ten- 
dency to that orgau. Under such circumstances, the very same 
means fail and prove injurious, which, applied so as to coincide 
with the time of the natural effort, would have been successful. 
To illustrate these principles by an example. We are con- 
sulted in the case of a young woman affected with various hys- 
terical symptoms for several months, and during that period 
more than usually subject to headache, languor, loss of spirits, 
diminution of appetite and irregularity, and usually constipation 
of bowels; she is pale, and complains of various pains and 
uneasy sensations, and has not menstruated since the appearance 
of these symptoms. Here it is evident that the constitutional 
treatment must be strengthening and tonic. The practitioner will, 
therefore, recommend regular hours, much exercise in the open 
air, a nutritive diet, and afterward cold shower-baths ; he will 
regulate the bowels, and afterwards prescribe a course of tonic 
medicines, chalybeates, preparations of bark, strychnia, etc. ; he 
will likewise inquire carefully when the last period happened, 
and where, and how often since that occurrence menstrual 
molimina were observed. He thus ascertains when they should 
again recur, and contents himself with enforcing the constitu- 
tional treatment until about six days before the calculated time. 
Then he lays aside the other medicines, and has recourse to those 
means which determine to the uterus. Two leeches are applied 
to the inside of the thigh, near the labium, every second night, 
until they have been three times applied. The bleeding is 
encouraged by stuping. On the intermediate days the bowels 
must be actively moved by aloetic pills ; and for three nights 
before and after the molimina, hot pediluvia, rendered stimu- 
lating by mustard seed, may be used. During the same time, 
also, frictions, with stimulating liniments, should be applied 
to the feet and legs every morning, and oil of turpentine or 
tincture of cantharides may be exhibited internally, while the 
necessity of more active exercise is inculcated. If these means 
fail, they must for the moment be laid aside, and the constitu- 



52 DISEASES OF THE OVAEIES. 

tional treatment must be again resumed, until the same number 
of days before the next period, when the list of remedies above 
spoken of must be again tried, and in few cases indeed shall we 
find them to fail. 



PEOF. T. GAILLAED THOMAS, M. D,, OF XEW YOEK, 

In cases of rudimentary or atrophied uterus, suggests local stimu- 
lation and distention. Every week or two it should be distended 
by a tent. In the intervals, an intra-uterine galvanic pessary 
should be worn. This, however, requires time. After general 
treatment, in cases of anaemia, etc., he uses other local stimulation 
by dry-cupping the cervix uteri. Electricity is of value. One 
pole of the battery may be placed over the lower part of the 
spine, and the other either passed over the hypogastrium, or 
brought in contact with the neck of the womb ; or it may be 
carried within that organ by means of a wire covered with a 
gum catheter. 

E. J. TILT, M. D., OF LONDON, 

Advises a couple of aloes and myrrh pills each night, to produce 
moderate alvine action ; the legs placed in a pail of hot water on 
rising, and a warm hip-bath at night ; mustard to the inner parts 
of the thighs and breasts on alternate nights ; the breasts dry- 
cupped, or rubbed with a stimulating liniment. On retiring, a 
linseed meal poultice as hot as can be borne to the lower part of 
the abdomen. These measures are to be tried for three days, 
and again after an interval of twenty-one days, and in the inter- 
val, a chalybeate is to be taken, and a bit of piline sprinkled 
with alcohol to be worn during the day over both ovarian 
regions. This he continues for three or four months. Occasion- 
ally, during the three days, he gives a mixture of acetate of 
ammonia, chloric ether, and fluid extract of ergot. When the 
head is much distressed, he applies six leeches to the labia, 
followed by a hot hip-bath, or a hot poultice to the labia. 



AMENORRHEA. 53 

He offers the following : 

15. R Oil of savin, f. 5 j. 

Spirits of nitrous ether, f. ^ iij. 

Mucilage, f-,lj- 

Water, ad f.^ vj. 

Shake well. Dose. — A teaspoonful every two hours, when the patient is 
half comatose from suppressed menstruation. 

Or, 

16. R. Tincture of ergot, f-EPJ- 

Syrup of saffron, f. % ss. 

Comp. decoction of aloes, f. % iss. M. 

Dosf. — A teaspoonful three times a day. 

He recommends the association of podophyllin and aloes, in 
pills, for the same purpose. 

PROF. KOBERT BARNES, OF LONDON, 

Thinks that the blood is in want of salines as well as of iron, 
and that this is the first want. He gives solution of acetate of 
ammonia, adding a little nitrate of potassa, and a light tonic, as 
hop, chinchona or calumba. He employs iron in the form of 
the ammonia-citrate, the solution of the acetate, or the dialyzed 
iron. Between salines and iron, he would give iodide of potas- 
sium in doses of five grains three times a day. He believes that 
the restorative power of iron is much iucreased by the addition 
of strychnine or ergot. 

PROF. J. B. FONNSAGRIVES, OF PARIS. 

This learned author divides amenorrhoea, for the treatment, 
into the following classes : 

1. Plethoric amenorrhea. Local and general bleeding, the 
resinous purgatives, and low diet, are here indicated. Siredey 
recommends in addition bicarbonate sodium, gr. v. daily, two or 
three days before the period; or solution of the acetate of 
ammonia. 



54 DISEASES OF THE OVARIES. 

2. Nervous amenorrhaoe, characterized by a condition of gen- 
eral nervous erethism. Racibobski in such cases gives twenty 
to thirty drops of the solution of acetate of ammonia, in hot 
water, several times daily, for three or four days before the 
period, and also has recourse at times to ergot and vag'nal fumi- 
gations with carbonic acid gas. 

3. Tuberculous and scrojulous amenorrhoea require the general 
treatment of dyscrasise. 

4. Amenorrhea by counter -fluxion. This arises when some 
other organ, by reason of its congestion, checks or prevents the 
normal uterine molimen of the menses. In such cases the atten- 
tion of the practitioner must be directed to removing the congested 
condition of the interfering organ 

DE. EMIL DILLENBEEGER, VIEKtfA. 

Treatment demands the removal of those errors and lesions 
which lie at the bottom of the malady. If the amenorrhoea con- 
sists of, some anomaly of the sexual organs, congenital or 
acquired, and such as cannot be remedied, or in some other irre- 
mediable malady, treatment is useless. If menstruation has been 
already established, the physician must convince himself, by a 
careful examination, whether or not pregnancy is the cause of 
the cessation of the periods. Internally are used aloes and 
myrrh, as follows : 

17. R. Pulveris aloes, gr. lxviij. 

Pulveris niyrrhse, gr. xxxiv. 

Extract! glycyrrhiza?, q. s. M. 

For sixty pills. Two to four pills two or three times a day. 

18. R. Pulveris aloes socotrinse, 

Pulveris xnyrrlia?, aa gr. xlviij. 
Croci sativi, gr. xxxiv. M. 

Extracti glycyrrhizae, q. s. 

For ninety pills. From four to six twice a day. 

Or, savine, as follows : 

19. R . Pulveris frondis sabinae, 

Sacchari albi, aa gr. xxxiv. 

Olei menthae piperita?, gtt. iij. M. 

Divide into six powders. One to be taken three times a day. 



AMENORRHEA. 55 

20. R. Olei sabinae, gtt. vj-xij. 

Sacchari albi, gr. lx. M. 

Divide into six equal powders. Put in waxed paper. Take one powder 
three times daily. 

21. R. Pnlveris frondis sabinae, gr. lxviij. 

Croci satavi, gr. xxij. 

v Olei sabinae, gtt. viij. 

Extracti gentianse, q. s. M. 

For sixty pills. From three to five pills two or three times daily. 

Or, direct crocus and borax, as follows : 

22. R. Boracis venalis, gr. xxxiv. 

Croci sativi, gr. xiij. 

Sacchari albi, gr. xxij. 

Olei menthae piperita^ gLt. j. M. 

Divide into six powders. One powder three times a day. 

Atnenorrhcea is often more certain to be cured by putting an 
end to serous or bloody discharges from various organs, by treating 
for an improved condition of the blood, with good nourishment 
and a corresponding regimen, with iron, preparations of cinchona, 
cold washing, etc., than by the employment of emmenagogues 
without any plan. 

For outward application the following are useful : Warm 
uterine douche ; brushing the mouth of the womb with tincture 
of iodine; leeches to the portio vaginalis uteri, to the labia 
pudendi, to the inner side of the thighs, or to the perinseum ; dry 
cuppings and mustard poultices to the inner side of the thighs ; 
warm, stimulating foot-baths, with mustard, salt, potash, or 
aqua regia ; warm sitz-baths, or half- baths; bath at Ems, etc. 
In many girls marriage is the first thing that regulates the men- 
struation. 



DR. 



This writer gives the following directions in the Union Medi- 
cate, No. 151, 1878. If the flow has been suppressed by the 
patient's catching cold, warm hip-baths, vapor-baths, and stimu- 
lating foot-baths will be found useful. The patient must he 



56 DISEASES OF THE OVARIES. 

well covered with warm clothing, and take sudorific drugs and 
stimulants, such as ether, acetate of ammonia, or infusion of lime 
blossoms. Hot fomentations must be applied to the lower part 
of the abdomen and the genital organs, and mustard plasters to 
the inner surface of the thighs; cupping might be advisable 
instead of mustard. Stimulating injections will also be found 
very useful. 

This treatment has to be continued for some days, and renewed 
when the next period is due. If the patient is plethoric, and 
congestions have been determined in the pelvic organs by the 
suppression of the period, leeches must be applied to the per- 
inseum, the labia, or the thighs cupped, and if the patient be 
constipated, a purgative must be given. If the suppression be 
caused by some moral cause, and the woman is excitable, the 
nervous system must be treated with antispasmodics and sedative 
drugs. 

HOSPITAL OF THE UNIVERSITY OF PENNA., PHILADELPHIA. 

In amenorrhea! from anaemia and chlorosis, the following pre- 
scription embodies the hospital practice: 

23. R . Pulv. ferri sulphat., 

Pottasii carb. purse, aa £ij. 

Mucil. tragacanthi, q. s. M. 

Div. inpil. No. 48". 
To be given daily in doses gradually increasing, until three pills are taken 
after each meal. 

This gives the large quantity of twenty-two and a half grains 
of the dried sulphate of iron per diem. 

To counteract the possible costive effect of the sulphate of 
iron, this aperient mixture is given ; 

24. R . Pulv. glycyrrhizse rad. 

Pulv. senna?, aa % ss. 

Sulphuris sublim., 

Pulv. foeniculi aa ^ij. 

Sacchar. purif. 5 iss. M. 

One teaspoonful in half a cupful of water at bed-time. 



AMEX0RRHO7A. 57 

Where the disease is due to torpidity of the ovaries, this pre- 
scription is used : 

25. R Ex. aloes, gj. 

Ferri sulphat. excic., ,"ij. 

Assafoetidse, 3 iv. 

SiG. — One pill after each meal. The number to be gradually increased 
to two and then to three pills after each meal. If the bowels are at any time 
over-affected, return to the initial dose of one pill after each meal. 

DR. L DE SINETY, OF PARIS. 

Little confidence can be placed on the so-called emmenagogues. 
Iron, when the amenorrhoea depends on chlorosis, mercury and 
iodide of potash, when syphilitic symptoms are present, and cod- 
liver oil in phthisical cases, will often bring back the flow. Where 
excessive adiposity is present, a diet of lean meat, green vegeta- 
bles, with abstinence from fluids, bread a»d other farinaceous 
substances will be effective. Once or twice a week a purgative 
of scammouy or salines should be administered. 

When there is a sluggishness of the utero-ovarian apparatus, 
the resources are a good hygiene, light gymnastics, open-air ex- 
ercise, cold and hot douches, hot sitz-baths, and sinapisms to the 
mammae and inside of the thighs. 

Catheterism of the uterine cavity, and intra-uterine pessaries, 
advocated by some, are modes of treatment with which this au- 
thor expresses little sympathy ; while electrization, on the other 
hand, either with the faradic or direct current, he has seen pro- 
duce positively beneficial results. The current should pass from 
within the vagina to the external abdominal wall. 

PROF. COURTY, OF PARIS. 

26. R . Pulv. rutte, 
Pulv. sabinse, 



For one pill. 



Pulv. ergotse, **<* & ±. 4 . 

Pulv. aloes, gr. f-f . M. 



Of these, thirty are ordered, and three are taken the first day 
six the second day, and nine the third day, always in three doses 



58 DISEASES OF THE OVARIES. 

They are suited for cases of idiopathic amenorrhea, without 
great reaction on the economy, and when there is reason to sup- 
pose that the suppression of the menses is due either to an insuf- 
ficient determination towards the genital organs, or to a difficulty 
of discharge due to inertia of the uterus. In order to encour- 
age the influxion towards the genital organs, Dr. Courty orders, 
before beginning the pills, foot-baths, sitz-baths, and fumigations. 
He also applies leeches to the labia during the three days the 
pills are being taken. The pills generally induce colicky pains, 
and often a little diarrhoea. 

KESUME OF EEMEDIES. 

Achillea Millefolium {Yarrow.) Dr. Ronzier-Joly reports 
very successful use of this plant in amenorrhoea in tu- 
berculous girls. He uses an infusion of the flowering 
tops, 3iij. to aquse Oj. Stille believes that this 
plant possesses peculiar relations to the pelvic organs. 
It is especially called for where imperfect or absent 
menstruation depends upon a condition of atony in the 
reproductive organs. 

Aconitum may be employed, in the form of the extract, with ad- 
vantage in amenorrhoea. Dr. Rjnger, of London, 
recommends it in the sudden suspension of the menses, 
as from cold. 

Aloes, in a small enema, containing gr. x., employed at the proper 
menstrual period, is said to be a very certain emtnena- 
gogue. Dr. E. J. Tilt, of London, recommends its 
internal administration combined with podophylliu. It 
is frequently combined with myrrh. 

Aloin. Dr. Tilt gives : 

27. R . Aloin, gr. ij. 

Cocoa butter, gr. x. M. 

Make a suppository. 

Ammonii Murias, in the hands of Dr. Anstie, in ten-grain 
doses, three times a day, in cases of amenorrhoea, 
marked rather by general feebleness than by anaemia, 
has occasionally seemed to conduce directly and con- 
siderably toward the cure. But of this, as of all 



AMENOERHCEA. 59 

other ermnenagogues, it is pre-eminently true that it is 
worth absolutely nothing if not exhibited precisely on 
the fit occasion. 
Ammonice Aqua has been successfully employed in the form of 
injection into the vagina : 

28. R. Aquas ammonise, f-S»j« 

Lactis, Oj.-ij. M. 

To be injected into the vagina daily. 

Apiol is highly recommended by Dr. Jaeet (Bull. Gen. de 
Therapy August 15th, I860,) and others since, as one 
of the safest and best of emmenagogues, not being 
even contra-indicated in incipient pregnancy. It is 
said to be especially adapted for cases attended with 
local or general nervous symptoms. A granule or 
" pearl " may be taken, gr. iv., four times a day. 

Argenti Nitras, applied in substance lightly to the os uteri 
at the time of the expected appearance of the menses, 
has proved successful in obstinate cases. 

Artemisia Vulgaris. The mug wort once enjoyed considerable 
reputation as an emmenagogue. 

Belladonna. In plethoric amenorrhcea, belladonna is an effica- 
cious remedy. It is quite popular on the continent, 
and recently Dr. F. T. Poetee, of Dublin, has re- 
ported marked success with it. 

Cantharides. Dr. W. P. Dewees placed much confidence in 
the internal use of tincture of cantharides, in doses of 
gtt. xx., gradually increased to gtt. xxxv. or xl. Dr. 
T. H. Tannee, of London, combined it with bro- 
mide of potassium. 

Cimicifuga has been found an effectual remedy in some cases. 

Cocculus. In nervous temperaments, with colicky pains, a few 
drops of the tincture several times daily, before the 
expected bow, will often relieve. 

Croeus Sativus. The saffron as a stimulant aromatic has efficacy 
in functional amenorrhcea. The celebrated " Pills of 
Rufus w are composed as follows : 



U, 



1. R. Aloes, 

Myrrhse, 

Croci, 

Syrupi absinthii, 


gr. iss. 
gr. 1. 

gr. eV 
q. s. 


or one pill ; five to ten pills daily, 





60 DISEASES OF THE OVARIES. 

*Ergot is recommended by Dr. Tilt, of London (in doses of 
gr. v-x., in powder, two or three times a day.) He 
usually gives it in conjunction with other remedies: 

30. R . Tincturse ergotse, ir^xxx. 

Syrupi croci, f. 3 ss. 

Decocti aloes compositi, f.^iss. M. 
A teaspoonful three times a day. 



Or, 



31. R. Li q. ext. ergot., f.gj. 

Prepared lard, gr. iv. 

Cocoa butter, q.s. ad. gr. xv. M. 
Make a suppository. 



*Ferrum Redactum, and the other ferruginous preparations, are 
indispensable in the anaemia which constantly accom- 
panies stoppage of the function. 

Galbanum may frequently be combined, with benefit, with the 
salts of iron. 

Hydrargyri Chloridum Mite is contra-indicated, if the patient be 
feeble, and is capable of doing much mischief in un- 
suitable cases. But Drs. Graily Hewitt, Ashwell, 
and others, have found it a decided emmenagogue. 
Dr. Hewitt directs that on two successive nights, at 
the time of the expected period, a dose be given of 
five grains of calomel and six grains of aloes, followed 
by a seidlitz powder in the morning. 

Iodine frictions over the abdomen have been found to give good 
results. 

Iodoform, internally, has been recommended. 

32. R. Iodoformi, 

Ext. gentianse, aa gj. 

Pulv. gentianse, q. s. M. 

Make 100 pills. Three to six daily. 

Mentha Pulegium. Pennyroyal has a popular reputation as an 
emmenagogue. 

Myrrh, in combination with iron and aloes, is a standard remedy 
in amenorrhcea. Dr. Tilt, of London, recommends 
the following so-called " Elixir of Paracelsus :" 



AMEXOttRHCEA. 61 

33. R. Tincturse myrrhae, f. 5 iv T . 
Tincturse croci, 

Tincturse aloes, aa f . 5 i i j . M. 

Dose. — ,"ij.-iij. twice daily, in a little water. 

Potassi Bromidum. The value of bromide of potash in amenor- 
rhea, especially that connected with nervous and hys- 
terical phenomena, neuralgia, ovarian irritation, scanty 
and painful menses, has lately been strongly urged by 
Dr. M. Rosexthal, of Vienna. ( Wiener Med. Presse, 
No. 46, 1878.) He repeats it in full doses for some 
days before the menses begin. 

Pulsatilla is said by Phillips to be of the greatest value in 
functional amenorrhea, and that following fright or 
chill ; gtt. j.-v. of the tincture three or four times a 
day. Pixtschovius recommends gr. j. of the extract 
thrice daily. 

Ruta Graveolens. The rue has been recognized as a direct 
emmenagogue since the time of Hippocrates. As it is 
a decided irritant of the intestinal canal, it must be 
given with caution. According to E. Hamelix (Did. 
des Sciences Medicales, 1877,) it is especially indicated 
where suppression is due to atony or inertia of the 
uterus. The powder is used by Dr. Courty. (F 26.) 
A better preparation is the essential oil. The follow- 
ing is from Dr. Dubois : 



M. 



A rectal injection of an infusion of rue, 3j. to Oj., 
is occasionally serviceable. 
Sabina is considered by Dr. Tilt, of London, as the most relia- 
ble of a very uncertain set of remedies. He has never 
seen any ill effects from its use, though he has given 
gtt. xx. of the oil twice a day. He orders : 

85. R. 



M. 



34. R . Olei rutse, 
Olei sabinse, 
Saochari, 

Kub together and add 


aa gtt. vj 
3vij. 


Aquae aurant. flor., 
A dessertspoonful every hour. 


f.:fiisi 



Olei sabinse, 


f.3J- 


Spiritus setheris nitrosi, 


f-5iij. 


Mucilaginis, 


f.|j. 


Aquae, 


f-3 V J- 



62 DISEASES OF THE OVARIES. 

A teaspoonful every two hours, the bottle being previously shaken. 
A plaster containing the oil may also be worn over the ovarian 
region. 

Pereira, Home, Phillips, Locock, and Sir 
Charles Clarke, all testify to its efficacy. 
Sanguinaria. R. Bartholow, M. D., regards sanguinaria as 
a positive emmenagogue. He uses the following: 

36. R. Tinct. sanguinaria?, ^5^5- 

Tinct. aloes, f-5 ss. 

Tinct. nucis vomicae, f-^ij- M. 

Twenty drops two or three times a day in amenorrhcea of anaemia. 

37. &. Sanguinarise, gr. ij. 

Ext. aloes, gr. x. 

Ferri redacti, 9j. M. 

Ft. pil. No. xx. 
One pill three times a day. 

Senega was first recommended as an emmenagogue by Dr. 

Hartshorne, of Philadelphia. He gave a pint of a 

saturated decoction daily during a fortnight before the 

expected appearance of the discharge. 
Sinopis. A hot mustard hip-bath is often useful, the patient 

remaining in it for an hour each time. 
Sodii Biboras. Dr. Copland recommends the following : 

38. R. Sodii biboratis, gss. 

Aloes socotrinse, 

Pulveris capsici, aa gr. xx. 

Olei lavandulse, q. s. M, 

Make eighteen pills. Take two thrice daily. 

Strychnia. Small doses of the extract or alkaloid of nux 
vomica, combined with aloes and myrrh, are sometimes 
of service. 

Tanacetum has a popular reputation. 

Terebinthince Oleum. Turpentine enemata have been given with 
success : 

39. R. Oil of turpentine, f.jfss. 

Barley water, O j. M. 

For one enema, to be given once or twice a day. 



AMEN'ORRHCEA. 63 

Zingiber. Hot ginger tea is a popular remedy for suppression 
from cold. 

GENERAL MEASURES. 

Electricity. This agent has been found useful in various in- 
stances. In chronic suppression, Dr. P. S. Hayes, of 
Chicago, places one of the electrodes alternately over 
each ovary and the uterus, the other electrode over 
either sacro-iliae synchondrosis, the current being fre- 
quently reversed. (Chicago Medical Examiner, Jan., 
1875.) Dr. Julius Althaus considers the most 
effective form of applying electricity in amenhorrhoea 
to be the induction of catelectrotonus of the ovaries. 
(Medical Times and Gazette, March 14th, 1874.) He 
places the negative electrode of the constant battery, 
alternately to the right and left ovarian region, putting 
the anode alternately to the lumbar spine and to the os 
uteri, by means of an insulated sound. The action should 
be kept up for fifteen minutes at a time, and repeated 
daily about the period the molimen should recur. 
The late Sir James Simpson was accustomed to use, 
with advantage, an intra-uterine galvanic or zinc and 
copper pessary, in the treatment of amenorrhoea, the 
result of imperfect development of the uterus. 

Leeches. Trousseau strongly recommended leeches. His method 
of using them was peculiar. He placed a single one, 
or at most two, on the thigh or knee at the time the 
menses were due. As soon as the leech fell, he ar- 
rested the bleeding, so as to promote congestion of the 
surrounding tissue. Sometimes, he asserts, the men- 
strual pains begin almost as soon as the bleeding is 
thus checked. 

Massage. This is appropriate in cases of suspended menstrua- 
tion. Dr. Douglas Graham, of Boston, has given 
some illustrations of its successful employment. (Boston 
Medical and Surgical Journal ', Feb., 1876.) The mode 
of procedure is manipulation of the whole body, with 
percussion of the back, resisting movements of the feet, 
legs and thighs, in all their natural directions; this 
being repeated daily. 

Milk Diet. A strict skim-milk diet has been found successful 
by Prof. Tarnier, of Paris, in several cases of amen- 



64 DISEASES OF THE OVARIES. 

orrhoea in obese young women. "With the disappear- 
ance of the extra fat, the menses returned. 
BaiJis. Sitz-baths or foot-baths, using salt water or mustard 
water, are often sufficient where there is suppression 
following exposure. The mustard should be placed 
in a linen bag and soaked with occasional pressure 
in the water, until the latter receives a greenish color. 
The time of the bath should be fifteen to twenty 
minutes. Atthill especially commends the cold hip- 
bath. He directs the patient to sit in a bath containing 
cold water, so as to cover the pelvis, the legs and feet 
not being immersed, but kept warm by coverings of 
flannel, or by a pan of hot water. The temperature of 
the bath should be about 60° ; taken at bedtime, and 
for a period of from five to fifteen minutes ; after which 
the patient should be well rubbed with a coarse towel, 
and put to bed. Chilliness must be obviated by a hot 
jar to the feet, and if there is discomfort after the bath, 
it should not be repeated, or used for a shorter period. 
This is not applicable where there is anaemia, or consti- 
tutional disease. 



DYSMENORRHEA. 

PROF. T. GAILLARD THOMAS, M. D., OF XEW YORK. 

Pursuing the classification of the forms of dysmenorrhoea, 
given by this authority (see page 52), he recommends the fol- 
lowing plan of treatment : 

Neuralgic Dysmenorrhoea. The skin should be kept warm 
and active by wearing flannel and bathing. If the rheumatic or 
gouty diathesis is present, colchicum, guaiac or vapor baths are 
called for. Chlorosis, plethora, or malaria, if present, should 
receive attention. A sound should be occasionally introduced 
into the uterus. Parturition often cures it entirely. Of specific 
drugs, apiol is the most reliable (one capsule night and morn- 



DYSMENORRHEA. 65 

ing.) Tincture of cannabis indlca, gtt. xxv. every fourth hour, 
will relieve the paiu. Where a spasmodic element exists, the fol- 
lowing is effectual : 

40. R . Extracti belladonnas, gr. J. 

Butyri cocoa;. q. s. M. • 

For one vaginal supj)ository. Eepeat every eighth hour. 

Enemata of tincture of assafcetida, f. 3ij. in a gill of warm 
water, often produce great relief in this condition. 

Congestive Dysmenorrhea. If from chill and exposure, opi- 
ates, diaphoretics and sedatives will give speedy relief; if from 
plethora, bleeding, cathartics and low diet are required ; if from 
a displaced uterus, as is often the case, this must be corrected. 
Local inflammations must receive attention before a cure can be 
expected. 

Obstructive Dysmenorrhosi. Constrictions of the cervix require 
enlargement, either by dilatation or incision. Sounds, tents, and 
dilators, are used for the first-mentioned methods. Sea-tangle, 
sponge, etc., are materials of which tents may be composed. 
Obstruction from flexion or version of the uterus requires a 
proper pessary or operation. 

Membranous Dysmenorrhea. This is relieved with difficulty. 
As soon as the menses begin, the patient should go to bed and 
apply hot-water bottles to the feet, abdomen and sacrum alter- 
nately. She should then take an enema : 

41. R. Tinct. assafbetidse, f. 3^ iij. 

Tinct. belladonnas, gtt. xx. 

Tinct. opii, gtt. x. 

Aquae tepidae, f^iijss. M. 

Throw the whole into the rectum and retain. Instead of this, 
the following may be given by the mouth : 

42. R . Chloral hydratis, 

Potassii bromidi, aa gij. 

Morphias sulphatis, gr. iss. 

Syrupi aurantii corticis, f-ifi'j- ^- 

A dessertspoonful in a wine-glassful of water every four hours,, 
while in pain. 

E 



66 DISEASES OF THE OVARIES. 

Ovarian Dysmenorrhea. The most efficacious remedies are 
the bromides of potassium and ammonium, in full doses, com- 
menced a week before the menstrual act, and continued until its 
close. A rectal suppository of gr. v. iodoform gives great 
relief. Change of air and scene, warm sitz-baths, or warm 
vaginal injections, and general hygienic measures, are essential. 

LAWSON TAIT, F. R. C. S., BIRMINGHAM. 

Ovarian Dysmenorrhea. In milder cases, treatment is gen- 
erally successful. First of all therapeutic remedies is iron, 
whether there are general indications for its employment or not. 
There can be no doubt but that many forms of this remedy exert 
a specific power over the sexual organs. It is best given during 
the intermenstrual period in small doses, liquor ferri perehloridi, 
gtt. j-v., well diluted, and increased suddenly to gtt. xv-xx., for 
a day or two previous to and during the menstrual flow; or an 
iron and aloes pill may be substituted for this large dose. Hot 
hip-baths and leeches to the perinseum at the period are useful 
additions, with an occasional blister on the sacrum. Marriage 
is, perhaps, the most efficient remedy, and one we ought seldom 
to hesitate to recommend. 

The last and most powerful aid' is mechanical irritation of the 
uterus. The most convenient and least troublesome is the inser- 
tion of Simpson's galvanic pessary. In a large number of cases 
this is beneficial ; but its use should be confined to those which 
resist simpler measures. Its introduction may give rise during 
the first week to considerable discomfort, but this passes off if 
the patient keeps her bed for a few days. It should be retained 
for several months. The uterus rapidly enlarges under its 
action, and the ovaries take part in this increased activity. Mr. 
Tait does not share the prejudice against this instrument which 
some writers have manifested. 



DYSMENORRHEA. 67 

CHARLES R. DRYSDALE, M. D., OF LONDON. 

This author maintains {Obstetrical Journal of Great Britain, 
Oct., 1875,) that there is too great a tendency to expect to find 
an evident physical cause for all painful menstruation. Spasm 
and neuralgia are quite sufficient to account for the vast majority 
of cases. Membranous shreds, also, are frequent causes of 
obstruction to the monthly flow. The rational treatment of 
dysmenorrhea commencing at an early period, consists not in 
the use of pessaries, or of incision of the uterus, but in the use 
of cold baths in the morning, with short walks in the open air 
afterwards ; in hot baths, a few days previous to the menstrual 
periods ; and in palliative treatment of the paroxysms by mea»s 
of antispasmodics at the epoch of pain. Marriage sometimes 
cures such cases at once ; at other times, it is of no use. 

PROF. J. MATTHEWS DUNCAN, M. D., OF LONDON. 

This teacher strongly advocates the treatment of dysmen- 
orrhea by mechanical means. He would not hesitate to employ 
it in virgins when the severity of the case was urgent. The 
treatment he refers to is that by bougies introduced into the 
cavity of the womb through the cervix. He states that it is 
unaccompanied by danger. The only evil result he has ever 
seen from it is a temporary perimetritis. It is a treatment the 
innocence of which arises from the fact that there is no cutting, 
and that the instrument' is not left in the womb above a few 
minutes at a time. It is allowed to remain until the pangs of 
pain which it brings on have passed. In order to effect a cure 
you must go up considerably above a No. 9. You must go up 
so as to stretch and distend the internal os uteri; and this 
stretching or distension of the internal os may require you, in 
different cases, to reach different sizes. A No. 11 is quite suffi- 
cient in many cases ; in others you will go up to a 12 or 13, 
rarely above that. These various numbers are not all used in 
one day, but in successive days, or every second or third day ; 



6$ DISEASES OF THE OVAEIES. 

and generally the whole is effected in a few sittings— say from 
four to eight. One is not to expect that this treatment will 
cure every case. By this treatment, he says that most of the 
characteristic cases are, if not cured, at least greatly ameliorated. 

PROF. F. A. ARAN, OF PARIS. 

This well-known gynecologist has highly praised the local 
application of opium in neuralgias of the uterine neck, which 
sometimes accompany dysmenorrhea {Bull, de Therapeutique, 
vol. LXVII.) His method is as follows : Having introduced a 
speculum, thirty to fifty drops of Sydenham's laudanum are 
allowed to flow to the bottom of the vagina ; sufficient pow- 
dered starch is then thrown in to form a magma with the lauda- 
num; upon this is placed a moderately large pledget of cotton, 
and the whole is left in the vagina, to be renewed daily or every 
other day, as occasion requires. He reports very great relief by 
this simple means. 



For therapeutical purposes this writer (Traite de Therapeutique 
Appliquee, 1878,) divides dysmenorrhcea as follows: 

1. Spasmodic Dysmenorrhea. The flow is normal in quantity 
and regular, but accompanied by sharp pains, and easily inter- 
rupted. The indications are, baths and anti-spasmodics, as an 
enema : 

43. R. Powdered valerian, 5>iij- 

Laudanum, gtt. x. 

Warm water, % viij. M. 
For a rectal enema. 

Or the valerianate of ammonia may be used in a similar man- 
ner. Hot poultices to the lower abdomen and sedative lotions 
to the hypogastric regions are also useful. Of internal reme- 
dies, two especially deserve mention, the acetate of ammonia and 
castor eum. The former should be given in doses of a fluid drachm 



DYSMENORRHCEA. 69 

well diluted, several times daily for several days before the 
period. Castoreurn is especially indicated where the pains are 
associated with distention of the bowels and tympanites, or when 
the discharge is scanty and tenesmus uteri present. Its power is 
then real and positive. It may be given in pill, powder, or 
ethereal tincture, in doses of gr. v-xxx. Its failure is often 
owing to the impurity of the drug. 

2. Dysmenorrhcea from general causes, as anaemia, plethora, 
nervous excitement, etc. As here the disturbance of the func- 
tion is merely symptomatic, it should be so treated. 

3. Dysmenorrhcea through insufficiency. When the proper 
amount of blood has not been lost, the woman experiences gen- 
eral discomfort, sense of weight at the hypogastrium, hysterical 
symptoms, obstinate headache, and local congestions. The indi- 
cation here is to supplement the menses by a moderate bleeding 
from the arm (f. liij-vj.,) or by leeches. 

4. Menorrhagic dysmenorrhcea is nearly always associated 
with the change of life, and will be considered under that 
section. 

5. Irregular Dysmenorrhcea. The quantity is normal, but 
the periods of return are irregular and the function painful. 
This is generally found either at the beginning or the close of 
menstrual life, or at the outset of diathetic disease. In other 
cases, it is proper to solicit the molimen at regular times by 



When there is evident hypersemia of the womb, several 
leeches to the portio vaginalis uteri, or to the insides of the 
thighs, warm soft poultices, or injections of lukewarm water, 
nre very beneficial. When the dysmenorrhoea is of nervous 
origin, some advantage is derived from the application of 
warmth, warm baths, mustard poultices, or dry cuppings ap- 
plied to the loins and thighs, and internally from narcotics, 
especially opium. 



70 DISEASES OF THE OVARIES. 

44. R . Pulveris opii, gr. j. 

Sacchari alibi, gj. 

Olei nienthse piperita;, gtt. ij. M. 

Divide into six powders. Take one every two to four hours. 

Or, 

45. R . Tincturse opii, TTLxxx. 

Infusi anthemidis, f-^iv- 

Aquae menthse piperita?, 

Syrupi simplicis, aa f.^ss. M. 

One to two tablespoonfuls every one or two hours. 



PEOF. THEODORE JEWETT, M. D., BOWDOIN MEDICAL COLLEGE. 

46. R . Carnphorae, ^ ijss. 

Extracti belladonnae, 

Quiniae sulphatis, aa gss. 

Pulveris acacise, q. s. M. 

For eighty pills. One to be taken every four hours until relieved. 

47. R. Extracti Scutellariae fluidi,'.' 

Decocti aloes compositi, aa f.^ss. M. 

A dessertspoonful every two or three hours until relieved. 

Dr. C. W. Frisbie, of East Springfield, N. Y., writes that 
he used the above formula in his practice many times, and, 
when the cases had been properly selected, with the most happy 
results. 

DR. A. DESPRES, OF PARIS. 

In dysmenorrhcea, warm water occasions congestion of the 
uterus, and the congestion is followed by a return of the menses, 
and consequently by a marked alleviation. 

Injections of warm water act like the cataplasms and warm 
lotions, which are so usefully employed in inflammation of the 
integument. 

The injections of warm water are practiced at the hospital with 
irrigators, of which the jet is not very strong. The water used 
should be of 95° to 104° Fah., and it is renewed two, four, or six 
times in a day. This therapeutic means is convenient, and not 
repugnant to the patient. 



DYSMENORRHCEA. 71 

DR. LISFRANC, PARIS. 

48. R . Vini opii, gtt. x-xx. 

Camphor a?, gr. ij-ivss. 

Decocti altha? f. 5 ijss. 

Vitel. ovi, 3 ijss. M. 

For an enema, to be given nearly cold, at bed-time, to relieve the 
pain of menstruation. Hot fomentations on the abdomen. 

49. R. Assafoetida?, 3j. 

Vini opii, ^ixv. 
Extract! Valeriana?, % ss. 

Decocti althae, f. 3 iijss. 
Vitel. ovi, 3 v. M. 

An ensema, in hysterical dysmenorrhea. 

HENRY HARTSHORNE, M. D., OF PHILADELPHIA. 

Whatever be the cause of dysmenorrhoea in any case, the sub- 
ject of it should always avoid being much on her feet for a day 
or two before her monthly time ; and should go to bed when 
the pain begins. Cloths wrung out of hot water, or whisky and 
water, may be placed on the abdomen and renewed as they cool. 
Internally the following may be given : ^ 

50. R. Spirittis camphorse, f«3J- 

Tinct. opii camp horatse, f-SiJ- 

Tinct. zingiberis, f. 5 ss. 

Tinct. lavand. compos., f. % ss. 

Aquam, ad f.^ ij. M. 

Take a dessertspoonful every hour or two. 

Large vaginal injections of hot water, and dilatation of the os 
and cervix, are other useful measures. No medicine appears to 
exert a prophylactic effect, unless it is iron in cases of anaemia. 



PROF. N. S. DAVIS, M. D., OF CHICAGO. 

Rheumatic Dysmenorrhoea. This practitioner has called atten- 
tion (American Practitioner, October 1877,) to a numerous class 
of cases of dysmenorrhoea from chronic rheumatic irritation : 



72 DISEASES OF THE OVARIES. 

First, the patient should wear constantly good warm under- 
clothes of flannel, eat plain, easily-digested food, drink no kind 
of stimulating drink, and take a full, warm alkaline bath twice 
a week. On getting out of the bath the water should be wiped 
off quickly, and the whole surface briskly rubbed with dry flan- 
nel, which brings a pleasant feeling of warmth and elasticity. 

Secondly, medicines should be prescribed on the same princi- 
ples as we would for chronic rheumatic irritation in any other 
structure of the body. Whatever medicines are given, however, 
must be continued faithfully from two to four months, during 
the interval between each menstrual period. 

Treatment during the menstrual week can have no effect 
beyond palliating the suffering of the patient temporarily. To 
become curative it must be extended through the interval, for 
the purpose of so changing the condition of the uterine structure 
and sensibility as to prevent the recurrence of the pain at the 
next period. 

In the most common class of cases, in which the pain is severe 
and the flow scanty, Dr. Davis has for many years used suc- 
cessfully the following formula : 



Tmct. stramonii, f.^ss. 

Vin. colchici rad., f.^ ss. M. 

Take one drachm at each meal-time, in water. 



If, by long continuance or unusual susceptibility, the cimici- 
fuga causes dull headache, as is sometimes the case, either the 
dose should be lessened, or the fluid extract of cypripedium may 
be substituted in its place. In the same manner, if the colchi- 
cum should cause disturbance of the bowels, its quantity must 
be lessened in proportion to the other constituents. 

Another prescription with which he has succeeded in many 
instances, especially when the pain and soreness extended to the 
region of the ovaries, is as follows : 



DYSMENORRHEA. 73 

52. R. Ammonia? hydrochlor., 5 iij. 

Tinct. stramonii, f.^ss. 

Tinct. cimieifugse rac, f. ,5 iss. 

Syr. glycyerhizae, f.^ ij. M, 

Teaspoonful three times a day. 

Another useful prescription is : 



53. R. Acidi salicylici, 




3*%.] 


Sodii biearbonatis 3 




3ij- 


Tinct. stramonii, 






Yini colchici radicis, 




aa f . % iv. 


Glycerinae 




in 


Aqua?, 




f-sm- 


Teaspoonful four times a day, in 


water. 





m. 



In connection with their medical treatment, Dr. Davis in- 
structs his patients to place themselves in the " knee and chest" 
position for a few minutes three times a day. The hips are high, 
the knees and chest low, thus throwing the uterus by the force 
of gravity into its natural position. Any form of pessary only 
adds to the sufferings of these patients. 

DR. JULIAN S. WOODRUFF, OF SOUTH CAROLINA. 

To meet the severe pain which occurs in some of these cases 
of dysmenorrhea, this writer states, when morphine and atro- 
pine are combined in solution and injected under the skin for 
the relief of the suffering, their instantaneous effects are truly 
wonderful and charming. An injection of this combination sub- 
cutaneously has in three minutes extinguished all pain, the patient 
straightening out and laughing and talking. 

DR. HENRY E. WOODBURY, OF WASHINGTON. 

The treatment of this practitioner (Va. Med. Monthly, Sept., 
1878,) is to introduce a very small tent of elm bark into the 
cervix about a week before the menstrual flow commences. After 
introducing the tent, a plug of cotton, to which a cord is attached, 
is passed through the speculum to keep the tent in situ. The 



74 DISEASES OF THE OVARIES. 

plug is then saturated with carbolic acid and olive oil, or glyce- 
rine, in the proportion of 1 to 7. By means of the cords at- 
tached to the tent and plug, the patient removes them next 
morning, and uses an enema of water and castile soap. In an 
obstinate case, a tent is used every day up to the time at which 
the now should commence, unless it is established sooner, sub- 
stituting larger and larger ones as the cervical cavity becomes di- 
lated. As soon as the tent, on removal, is found to be freely 
stained with blood, its use is suspended until a week before the 
next period. 

The remedies administered internally are concentrated tincture 
of helonias, fluid extract of ergot, tincture of gelsemium ; or 
syrup of the iodide of iron. The patient commences to take one 
of these three weeks before the regular date of her flow, and 
continues it till this is fully established. She then suspends it 
for a week or ten days, after which she resumes it. Sometimes 
better results are obtained by using two of the above-mentioned 
remedies alternately, as the helonias and the iron, or the ergot 
and iron. A gentle current of electricity is passed through the 
uterus once a day for two or three days before the period. This 
treatment has been successfully employed in cases of dysmenor- 
rhea due to subacute inflammation or displacement, resulting in 
the constriction or occlusion of the cervix. 

DR. JOHN WILLIAMS, OF ENGLAND. 

Membranous Dysmennorrhcea. — This writer (Obstetrical Titans- 
actions, 1877,) is of opinion that the inflammation of the inter- 
nal surface of the uterus, often found in these cases, is the re- 
sult, not the cause, of the membranes, but is the result of the 
membranous dysmenorrhoea. He does not believe they are the 
results of abortion, as they frequently occur in virgins. The 
source of mischief must be looked for in the walls of the uterus 
itself. The membrane is the decidua ordinarily shed as debris 
at menstruation. Dr. Williams thinks there is something 
wrong in the uterus from puberty ; in fact, imperfect evolution. 



DYSMENORRHEA. 75 

As regards treatment, everything should be done to favor the 
physical development of the young girl. Once the condition is 
established, the only means whereby a cure is likely to be ef- 
fected is electricity, either in the form of the continuous current, 
or by a galvanic stem. • 

DR. L. DE SINETY, OF PARIS. 

This author believes that the so-called congestive dysmenorrhosa 
is merely an exacerbation of chronic metritis at the menstrual 
period ; and that the so-called nervous dysmenorrhosa is a neural- 
gia with a uterine point, becoming more sensitive at the catame- 
nia. In the latter cases, the sensitive point persists in the inter- 
menstrual period, and may be found at the juncture of the uterine 
neck and body. True dysmenorrhea is nearly always symptom- 
atic of an affection of the uterus or its annexes, and generally 
depends on a mechanical obstacle. A small polyp, a blood-clot, 
or a shred of mucous may cause painful and obstinate dysmen- 
orrhea. 

The treatment, therefore, should be mainly mechanical. Pro- 
gressive dilatation, by introducing a bougie daily into the cer- 
vical cavity and leaving it a quarter of an hour, gives excellent 
results. If this fails, we must have recourse to general meas- 
ures, as tonics, hydrotherapy and electricity. Local and general 
narcotics may be called for to relieve pain. The introduction ot 
chloroform vapor into the vagina is an efficient anodyne. The 
following rectal injection, administered after having emptied the 
rectum, and retained as long as practicable, is an efficient calm- 
ant: 

54. R . Tincture opii, gtt. x. 

Camphora? pulveris, gr. xv. 

Vitelli ovi, j. 

Aquse frigida?, O j. M. 

For an injection. 

In membranous dysmenorrhosa the local treatment is essentially 
the same. The indications for general treatment must be based 
on the diathesis. Thus, iodide of potash or cod-liver oil, useful 



76 DISEASES OF THE OVARIES. 

in some cases, must in others be replaced by arsenic or the alka- 
lies. Electricity has given excellent results in some cases of this 
nature after every other resource has been exhausted. When 
there is decided endometritis, cauterization of the internal sur- 
face of the uterus, preferably with the silver nitrate, is valuable ; 
but where the pathological process consists in simple hypertro- 
phy or an exaggerated desquamation of the normal mucous coat, 
such a proceeding would be useless, if not injurious. Hence, a 
careful microscopic study of the exnelled product should precede 
any such operation. 

KESUME OF KEMEDIES. 

*Ammonice Acetatis Liquor. In painful menstruation, f. 3j. doses 
of this preparation of ammonia, given every hour 
when the pains come on, will often be found to lessen 
or wholly dissipate them. Barnes recommends : 

55. R . Spiritns petheris comp., f. 3 ss. 

Liq. ammo, acetat., gtt. xv. M. 

For one dose several times daily. 

Ammonice Murias. The following is highly recommended by 
Dr. O. Ward, of Tennessee, in the painful dysmenor- 
rhoea of the climacteric period. 

56. R • Ammonite muriatis, gij. 

Extracti glycyrrhizpe, % ss. 

Aqua?, f-.^vj. M. 

A dessertspoonful three times a day. 

Amyl Nitrite has been found of great benefit in spasmodic dys- 
menorrhcea by Dr. Mary Putnam Jacobi, especially 
when supported by belladonna, commenced previous 
to the beginning of menstruation. (New York Medi- 
cal Record, Jan. 2d, 1875. ) Or it may be given in 
one-drop doses in peppermint water every half hour. 
(Sell.) 

Apiol, in the hands of Dr. Tilt, of London, acts like a charm 
when given in doses of four grains, so soon as the 
pains of dysmenorrhcea begin. It is of little use, 
however, when the dysmenorrhcea depends upon dis- 



DYSMENORRHEA. 77 

ease of the uterus. It is also of decided efficiency in 
fetid menstruation. 

Arsehiosum acidum, in dysmenorrhea associated with anaemia, is 
often advantageous, as : 

57. R. Tincturae ferri chlor. £x. 

Liquor, potassse arsenitis, 3 ij. M. 

Sig. — Twelve drops after each meal, through a glass tube, in about 
one-third glass of water. 

* Belladonna. In neuralgic dysmennorrhcea, Dr. Anstif, of 
London, recommends (British Medical Journal, August 
22d, 1868,) the extract, as a palliative, in doses of gr. 
^. He obtained still better results from the hypo- 
dermic injection of the sulphate of atropia, in doses of gr. 
1 /l20~ 1 /60 lw i ce a day, and continued for several weeks, 
at once reducing the quantity when marked dryness of 
the throat appeared. In constitutions very intolerent 
of belladonna in any form, the acetate of morphia 
may be advantageously substituted for the atropia. A 
belladonna plaster to the sacrum is often of benefit; 
so also is a suppository of extract of belladonna. 

Brominium acts efficiently, according to Barnes, in ovarian 
dysmenorrhea. 

Camphor. Dr. Dewes regards camphor as a very certain and 
uniform palliative, in doses of gr. x. every one or two 
hours, until relief be obtained. Or the following in- 
jection may be given : 

58. R. Camphorse, ,5ss.-j. 

Tincturse opii, f-3J- 

Mucilaginis, q. s. M. 

For an enema. 

Camphor liniment, or ointment, well rubbed into 
the loins, also affords relief. 

Cannabis Indica is sometimes a useful remedy. 

Cimicifuga. The eclectic practitioners speak of this as a most 
efficient remedy in dysmenorrhcea, and temporary sup- 
pression from cold, or where there is a rheumatic 
diathesis. Phillips endorses this statement from 
his own experience. (Mat Med., 1879.) (F. 51.) 

Colchicum is useful in dysmenorrhcea connected with a tendency 



78 DISEASES OF THE OYAEIES. 

to gout or rheumatism. It should be given with blue pill 
every other uight; flannel at the same time should be 
worn, and exposure to cold avoided. (F. 53.) 

Cocculus Indicus. In thin and nervous females, where the dis- 
charge is scanty, and preceded by paroxysmal griping 
pains, Dr. C. D. Phillips (Mat. Med. and Ther., 
1879,) states that the administration of cocculus, com- 
menced a few days before the period, will frequently 
ward off the pains and render the discharge natural. 
The dose is ^f[ij.-x. of a tincture 1-8. 

Codeia, gr. J, highly commended by Aean, often agrees where 
opiates do not. 

Crocus Sativus. The saffron is much employed by French prac- 
titioners in dysmenorrhcea, both as infusion and tinct- 
ture, and also locally. The following " cataplasme 
antispasniodique " is highly recommended in painful 
cases : 

9. R . Croci contusi, 3 iij. 

Pulv. camphorae, 

Opii pulveris, aa £j. 

Lini, | viij. 

Aquse ferv., , q. s. M. 

Mix the saffron and opium with a little water, and then stir this 
and the camphor into the poultice and lay it warm upon the 
painful uterus. It is especially grateful in " uterine colic," or 
" uterin rheumatism." 

*Ergota is often of excellent service, especially in the congestive 
form ; 3 ss. of the fluid extract every half hour may 
be given. 

*Ferri Chloridi Tinctura and Ferri Vinum are both excellent 
preparations in ovarian atonic dysmenorrhcea. Sir 
Chaeles Locock recommends the following formula : 

60. R . Vini ferri, 

Spiritus aetheris sulphurici 

compositi, aa f. 5 j. 

Mixturae camphorae. f.]| vj. M. 

Take one-fourth part every six hours. 

Gossypium. Dr. L Alexandee, of Pennsylvania, has found 
much benefit in the following : 

61. R. Extracti gossypii fiuidi, f. ^ ij . 

Extracti ergotae fiuidi, 

Tinct. hellebori nigri, aa f.^j j. M. 



D YSMEXOKRHCE A . 79 

Teaspoonful every three hours, commencing two or three days be- 
fore the expected attack. 

*Guaiacum is often productive of the greatest benefit. The 
tinctura guaiaici ammoniata is especially servicable. In 
ovarian and rheumatic forms, it deserves to be called 
a specific. In chronic cases, it should be accompanied 
by the iodide of potassium. 

Oleum Terebinthince, in does of gtt. xx., thrice daily, with 
warm baths, is recommended in membranous dysmen- 
orrhcea by Trousseau. 

* Opium. Opiates are often best exhibited in the form of ene- 
mata. Dr. E. J. Tilt, of London, recommends a hot 
linseed-meal poultice, sprinkled with laudanum, to be 
applied to the hypogastrium. A single hypodermic 
injection of morphia, when the pain is habitually se- 
vere, will often be sufficient at each menstrual period. 

*Potassii Bromidum. This sedative is especially valuable in 
neuralgic, ovarian and membranous dysmenorrhoea. It 
should be given in large doses, prior to the commence- 
ment of the period. 

Potassii Nitras has been found highly serviceable, in doses of 
gr. xv.-xx., well diluted with barley water. 

Pulsatilla, in tincture or extract, has been well spoken of, 
especially in the ovarian forms. Dose, gtt. iii.-x. of 
the fresh tincture. 

Sinapis. Dr. Ashwell recommends the mustard hip-bath, to 
be repeated three or four times a day, the patient re- 
maining in it for from thirty to sixty minutes, or even, 
if the pain be very severe, until faintness is induced. 

Sodii Biboras is of advantage combined with extract of bella- 
donna. 

Stramonium is said to be of marked benefit in the severe form 

of the disease. 
Taraxacum. A half-teaspoonful of the extract in a little warm 

milk every night proves useful, by keeping up a 

healthy action of the liver and skin. 
Veratria. Mild veratria ointment, rubbed over the hypogastric 

region twice a day, greatly relieves the pain. 
Viburnum Prunifolium affords often great relief if taken for a 

few days before the menses appear. Dr. E. W. Jenks 



80 "DISEASES OF THE OVAEIES. 

(Trans, of the Amer. Gyn. Soc, 1876,) states that in all 
forms of dysmenorrhea attended with profuse menstrua- 
tion, it is of much value, but where the flow is scanty, 
it does not prove beneficial. It is not sufficiently seda- 
tive, if given alone, freely, to relieve the sufferings of 
spasmodic or neuralgic dysmenorrhea ; but it is a val- 
uable adjunct to sedative and antispasmodic remedies. 
The dose is f. 3ss.-j. of the fluid extract, three or four 
times a day. 

MECHANICAL REMEDIES. 

Galvanism. Dr. Wm. B. Neftel (New York fifedical Record, 
Oct. 6th, 1877,) gives notes of the cure of two cases 
of aggravated dysmenorrhoea of long standing, which 
had been treated thoroughly but unsuccessfully, by 
some leading gynecologists, but which readily yielded 
to treatment by the galvanic current. He believes that 
dysmenorrhoea is essentially of nervous origin (a vis- 
ceral neuralgia), though it is frequently accompanied 
by structural or mechanical derangements of the womb ; 
and that these derangements are frequently the eon- 
sequences of the nervous affection rather than the 
cause thereof. 

Rapid Dilatation of the canal of the neck of the uterus in pain- 
ful menstruation resulting from a narrow and re- 
stricted condition of the uterine canal, has been very 
successfully applied by Dr. Ellwood Wilson, of 
Philadelphia, (American Gynecological Transactions, 
1877.) This he accomplishes by means of an instru- 
ment designed for the purpose. 



MENORRHAGIA AND METRORRHAGIA. 81 



MENORRHAGIA AND METRORRHAGIA. 

PROF. ROBERT BARNES, OF LONDON, 

Says in all cases of hemorrhage from the uterus, obtain and 
maintain a patulous condition of the cervical canal. This, of 
itself, often arrests the bleeding. Remove everything in the 
shape of a foreign body, as clots, retained ova, membranes, or 
placenta. To do this, one or two fingers may be passed in to 
break them up. Haemostatics may be introduced by means of a 
swab of cotton wool, twisted on a roughened probe ; or where, 
by reason of the narrowness of the canal, this is impracticable, 
injections or solid styptics may be used. The best way is by 
inserting small bits of sponge in a tube made like the uterine 
ointment positor, and saturating this with the styptic. The tube 
is then passed into the uterus, and pressure of the piston squeezes 
out the fluid, drop by drop, upon the bleeding surface. This 
failing, the styptic must be injected boldly. 

In passive hemorrhage, the general vascular tension, the 
increased action of the heart, and the determination of blood to 
the pelvic organs, must be moderated. The most useful agents 
here are digitalis, aconite, bromide of ammonium or potassium, 
sometimes opium, ipecacuanha, chloral, salines, as acetate of 
ammonia, nitrate of potassa. Cold is often useful. Ice in the 
vagina or cold water injections should always be tried early. 

Position is important ; keep the pelvis above the level of the 
body. 

Saline purgatives especially operate with advantage. Inter- 
nally, the most useful are turpentine in capsules, ergot in fluid 
extract or powder, or ergotine, tincture of hamamelis in five or 
ten-drop doses every three or four hours, quinia, strychnia?, sul- 
phuric or phosphoric acid, tannic or gallic acid, acetate of lead, 
the vinca major, Indian hemp, ipecacuanha. All failing, styptics 
locally must be used. The after-treatment does not at first 
require iron ; this only adds fuel to the fire ; the system requires, 

F 



82 DISEASES OF THE OVARIES. 

first, salines, these serve better to replenish the exhausted circu- 
lating fluid. They subdue vascular excitement, allay fever, 
calm nervous irritability, improve the secretions, and prepare the 
way for iron and other tonics. The best form of saline is the 
freshly prepared acetate of ammonia ; to this may be added a 
sedative, as Battley's solution, and sometimes digitalis or aconite. 
Later, hamamelis, ergot, quinine, mineral acids, and a decoction 
of bark, and later still, iron. The best forms are the citrate, 
acetate or chloroxide in an effervescent form, or the dialyzed 
iron, at first in small doses to feel the way. Sleep is of signal 
service, opium with the saline, or as the compouud opium pill in 
five- grain doses, or as pulv. ipecac, com p., ten grains. If not 
well borne, we have a precious resource in chloral, in scruple 



This author says that in cases of menorrhagia the patient 
should be kept perfectly quiet upon her back ; cloths wrung out 
of cold water should be laid over the uterus, vulva and thighs ; 
cold acidulated drinks should be given freely; and the injection 
of all warm fluids strictly interdicted. In addition, the apart- 
ment should be kept cool, the nervous system quieted by opium 
or an appropriate substitute, and all conversation prohibited. In 
mild cases this may suffice, but in severe ones it will not. Then 
the speculum should be introduced, a sponge-tent passed into the 
cervix, and the vagina filled with a tampon. This will rarely 
fail. But iu certain cases, as, for instance, those of cancer of the 
neck, the tent will not be admissible. Under these circumstances, 
a soft sponge or wad of cotton should be saturated with a solu- 
tion of persulphate of iron, laid upon the cervix, and the tampon 
placed against it; or a small linen bag may be filled with pow- 
dered alum, placed in contact with the cervix, and held in place 
by a tampon; or two drachms of tannin may be left free against 
the part. To these means almost all cases will temporarily yield, 
more especially if the use of the tent is admi sible. 

Where the menorrhagia is due to a fungus degeneration of the 



MENORRHAGIA AND METRORRHAGIA. 83 

intra-uteriue membrane, the curette is a most valuable resource ; 
or the lining membrane of the uterus may be modified by ener- 
getic agents, as nitric acid, tincture of iodine, nitrate of silver, etc. 
In very obstinate cases, change of climate will often prove of 
decided benefit. 

PROF. ROBERTS BARTHOLOW, M. D., PHILADELPHIA. 

When menorrhagia is the result of impoverished state of the 
blood, iron is the most appropriate medicament. It may be 
combined with arsenic. 

Gallic acid is very effective, as in the following formula: 

62. R. Acidi gallici, £ss. 

Acid, sulphur, dil., f-3J« 

Tinct. opii deod., f. ,^j. 

Infus. rosse comp., f. 3 iv. M. 
A tablespoonful every four hours, or oftener. 

When there is a large spongy uterus, ergot is indicated. When 
caused by ovarian excitement, bromide of potassium will promptly 
relieve. 

Ipecacuanha possesses very valuable anti-hemorrhagic powers ; 
it should be frequently repeated. 

63. R. Ext, ipecac, fluidi, f-.^ij. 

Ext. ergotse fluidi, f. giv. 

Ext. digitalis fluidi, f. ^ij. M. 

Thirty minims to a teaspoonful at a dose, as required. 

In debilitated and relaxed subjects, menorrhagia may be re- 
lieved by determining an afflux of blood to the uterine system. 
Iron and aloes may be here associated. But the latter would be 
contra-indicated where there already existed congestion of the 
pelvic viscera. 

EDWARD JOHN TILT, M. D., LONDON. 

This writer lays much stress on the importance, in severe 
cases, of placing the head on a level with the body. Sedatives 



84 DISEASES OF THE OVAEIES. 

are always beneficial. The bromide of potassium or of ammo- 
nium has been known to check the tendency to menorrhagia. 

In many cases damaging blood loss may be checked by the 
exhibition of full doses of the liquid extract of ergot and the 
tincture of digitalis, f. 3 ss. three times a day, as : 

64. R. Tin cturse digitalis, 

Extracti ergotse fluidi, aa f.^iij- 

Aquse destillatse, adf.^vi. M. 

The sixth part to be taken three times a day for three days. 

.While giving these remedies, a two grain-opium suppository 
should be passed into the rectum once a day, even if there be no 
pelvic pain, for opium has often helped to quell blood-flow. In 
any case, it is well to commence with small doses of ergot and 
digitalis a few days before the menstrual period is due. 



The treatment must of course in all cases have reference to 
the exciting cause of the profuse flow. Flexion or congestion of 
the uterus is frequently present. It must receive attention. 

The external employment of baths is of the greatest service, 
especially cold hip-baths and sponge-baths. Cold to the spine, 
by means of ice-bags, has proved of service. Injections of cold 
or iced water into the rectum is a valuable means of arresting 
the flow of blood in bad cases. 

Dr. Hewitt believes that styptics taken internally are fre- 
quently found very serviceable ; of them, he considers the most 
efficient to be matico in combination with tincture of iron, or 
the latter alone in large doses, yf\ xxx.-xl. Opium has been 
highly extolled, but does not appear to be adapted to chronic 
cases. 

Where the discharge is exhausting, stimulants and nourishment 
should be freely administered in small quantities at frequent in- 
tervals. 



MENORRHAGIA AND METRORRHAGIA. 85 

PROF. WILLIAM H. BYFORD, M. D., OF CHICAGO. 

This practitioner, in the Transactions of the International Medi- 
cal Congress, 1876, discusses in considerable detail the treatment 
of metrorrhagia. 

In the palliative treatment, isolation, quietude, and recum- 
bency, are very important cautions to be enjoined. Plain food, 
cool clothing, and general hygienic rules, are indispensable. In re- 
gard to drugs, Dr. B. has derived considerable advantage from 
astringents proper. The most generally applicable agent is 
ergot ; but it will usually fail when the flow is venous, as in 
retroversion, pelvic infarction, tumors, etc. When there is much 
pain in the pelvis, and a dry state of the skin, opium and ipeca- 
cuanha are very serviceable. When vascular and nervous excite- 
ment is prominent, lobelia, gelsemium, digitalis, aconite, and 
veratrum viride, are all of use. 

These measures failing, we must resort to either mechanical or 
chemical means. The former is represented by the tampon ; the 
latter by powerful hemostatics. They may be all advantageously 
combined, as in the plan proposed by Dr. Marion Sims. His 
hemostatic is : 

65. R. Liquoris ferri subsulphatis, f.^ss. 

Aquae, f. 3 j. M. 

The finest cotton wool is saturated with this, and then sub- 
mitted to moderate pressure and dried for use. Its application 
is made by wrapping a sufficient quantity around a long, small 
piece of whalebone, and introducing it into the cavity of the 
uterus, when the cotton is detached and left there. If the 
hemorrhage is moderate, one such piece will suffice; if severe, 
it will be necessary to stuff the uterine cavity full. Strong 
thread can be attached to the cotton to withdraw it when neces- 
sary. From twelve to twenty-four hours is as long as it should 
remain. 

In the intermenstrual period, curative measures should be 
resorted to, as alteratives, tonics and derivatives. Muriate of 



86 DISEASES OF THE OVARIES. 

ammonia will be found especially valuable. When debility is 
present, among the very best remedies is : 

66. R. Hydrargyri chloridi corrosivi, gr. tVtV 

Tmct. cinclionse compositse, f. ^ j. M. 

This amount thrice daily. 

Iodine, iodide of potassium, and iodide -of iron, are also effi- 
cient. A beneficial derivative measure is dry cups over the 
sacrum often repeated. The cups should be large, and allowed 
to remain for an hour or more. 

M. PANAS, M. D., OF PARIS. 

Among the various manipulative measures used in severe 
metrorrhagia, preference is given by this writer to plugging the 
cavity of the neck of the womb, which has several advantages 
over plugging the vagina in such cases. It stops the blood 
more effectually, the patients bear it better, and there is less 
chance of putrid absorption. The plan adopted by M. Panas 
consists of introducing into the cavity of the uterine neck a 
pledget of cotton wool, rolled up to about the thickness of a 
goose-quill, and steeped in a solution of the perchloride of iron 
of the French Codex, to which is added one jmrt of water, to 
prevent its caustic effects. 

This being done, he introduces a ball of cotton wool and 
places it in the posterior cul-de-sac of the vagina, where it not 
only forms a support to the uterine plug, but it absorbs any 
liquid that may escape through it, and thus protects partftf the 
vagina (which is covered with the peritoneum) from the corrod- 
ing effects of the perchloride of iron and the acrid discharges 
from the womb. 

DR. RUDOLF TAUSZKY, OF NEW YORK. 

The treatment adopted by this physician is thus briefly set 

forth in the Amer. Jour, of the Med. Sciences, January, 1881 : 

In the treatment of menorrhagia, metrorrhagia, or chronic 



MENORRHAGIA AND METRORRHAGIA. 87 

pelvic congestions and hypersemic conditions, rest, with pelvis 
elevated, is of the highest importance. Hot water injections and 
scarifications of the cervix and endometrium he has found bene- 
ficial. Salicylate of soda, quinia, digitalis in large doses, and 
opium — for the relief of pain and where a nerve sedative is indi- 
cated — are invaluable means of arresting uterine hemorrhages. 
Ergoiin in large doses, given before, during, and after menstrua- 
tion, every hour until the hemorrhage, if profuse, ceases, is one 
of our most valuable aids in arresting it. The use of intra- vagi- 
nal balls of the astringents, alum, tannin, and tincture of iron, 
preferably four grains of alum with a few drops of iron and gly- 
cerine, introduced every hour if the hemorrhage is alarming, or 
still better, the careful intra-uterine application down to the 
fundus of tannin and glycerine upon a probe, or of Monsell's 
solution of the subsulphate of iron, half diluted with water, have' 
checked uterine hemorrhages that have resisted treatment for 
months. He has never seen any ill-effects follow the intra- 
uterine application of iron in a large number of obstinate 
metrorrhagias in his own practice. Cauterizations in catarrhal 
endometritis, five or six days after the menstruation has ceased, 
repeated once a week, often cures the catarrh. 

VIENNA. 

The treatment of menorrhagia according to the Vienna school 
comprises rest, horizontal position with the pelvis elevated, low 
diet, and cooling drinks, such as : 

67. R. Acidi tartarici, gr. x.-xxij. 

Syrupi aurantii florum, f. % vj. 

Aquae, £3 xv. M. 

For drinking. 

68. R. Taraarindi, gj. 

Fiat decoctum librae unius, 
Acidi sulphurici aromatici, f. ^j.-ij.) 

Syrupi rubri, £5 ss.-j. M. 

For drinking. 



88 DISEASES OF THE OV ABIES. 

69. R. Acidi sulplmrici aromatici, f-^ij- 

Syrupi rubri, f.% j. M. 

One to two teaspoonfuls in a glass of water as a drink. 

These directions and prescriptions, together with pure air, only 
moderately warmed, in the room, are some of the most important 
points which alone will often restrain rather free bleeding. 

When there is passive hemorrhage, use 'cold dressings, injec- 
tions of cold water, or the following astringents : 



70. R. Aluminis, 
Aquae, 
For vaginal injections. 


Jij.-ivss. 


M. 


71. R . Acidi tannici, 
Aquae. 
For vaginal injections. 


% ss.-iv. 
f.gxv. 


M. 


72. R . Zinci sulphatis, 
Aquas, 
For vaginal injections, 


gr. x.-xxxiv. 
Oj. M. 


73. R. Catechu, 
Aquae, 
For vaginal injections. 


3ij. 

f.Jxv. 


M. 


74. R . Extracti kramerise. 
Aquae, 
For vaginal injections. 


3ij- 

f.^xv. 


M. 



Plugging the vagina is also an effectual remedy. 
AmoDg internal remedies, those that have generally shown 
themselves the best are : 



75. R . Ferri chloridi, gr. xvj. 

Tincturae opii, gtt. x. 

Syrupi tolutani, f.% ij. 

Aquae, f.]§ vj. 
A tablespoonful every one or two hours. 



76. R. Pulveris erj 

Sacchari albi, aa gr. xxxiv. 

Olei cinnamomi, gtt. j. M. 

Divide into six doses. One powder every five minutes. 



MENORRHAGIA AND METRORRHAGIA. 89 

77. R. Extracti ergota? fluidi, TT\,xx.-xl. 

Syrupi acacia?, f. % ij. 

Syrupi aurantii florum, f. 5 ss. 

Aquae, f.5 iij. M. 
One tablespoonful four times a day. 

78. R . Extracti krainerise, gr. vj.-xx. 

Aluminis, • 

Sacchari albi, aa gr. xxij. 

Olei cinnamomi, gtt. j. M. 

Divide into six powders. One powder every two or five hours. 

79. R, 



Aluminis, 


gr. xxx ij, 


Tincturae cinnamomi, 


f-PPJ- 


Syrupi aurantii corticis, 


f.^ss. 


Aqua? cinnamomi, 


f.3 iv. 



M. 
One tablespoonful hourly. 

EESUME OF KEMEDIES. 

Achillea Millefolium, the yarrow, has beneficial properties where 
the excessive flow depends on atony of the organs. 

Adda, The mineral acids internally have been familiar to the 
profession for many years as remedies for excessive 
flowing, but their efficacy has been doubted of late 
years. (See F. 68, 69.) 

Alumen often proves successful in controlling the hemorrhage. 
Dr. E. J. Tilt, of London, says that in uterine hem- 
orrhage, alum, in solution with sulphuric acid, is the 
first remedy to try. 

Ammonii Bromidum. In case of too frequent menstruation, not 
specially connected with menorrhagia, but rather with 
abnormal activity of the genital system, Dr. J. R. 
Black, of Ohio, has found decided benefit irom this 
drug, gr. x. four times daily, beginning at least a week 
before the expected molimen. (Half -Yearly Compen- 
dium, Jnly, 1879.) 

Argenti Oxidum is an efficient remedy in menorrhagia. More 
than three grains daily should not be given. 

Arseniosum Acidum. Fowler's solution is said to check uterine 
hemorrhage, given at first in the dose of TT^x.-xx., and 
repeated in ten-minim doses every twenty minutes until 
the discharge ceases. This remedy must not, of course, 
be pushed too far. In the Practitioner, February, 1880, 



80. R . Berberise sulphatis, 
Sacchar. albi, 


^iss. 


Make 12 powders. 





90 DISEASES OF THE OYAEIES. 

Dr. G. S. A. Ranking testifies to the great value of 
ten-drop doses of Fowler's solution in uterine hemor- 
rhage, given twice a day, either alone or in combina- 
tion with a mineral acid. 
Berber ice Sulphas. Dr. R. H. Andrews, of Pennsylvania, 
(Trans, of the Pa. State Med. Soe., 1877,) reports very 
satisfactory results with this drug in cases of profuse 
exhausting menstruation. He -prescribed the remedy 
as follows : 



M. 



One of these powders is directed to be taken when the 
flow is very free, or if not free in three or four days 
after the menses have appeared ; repeated in four or 
eight hours, according to indications. The effects of 
such an administration of the remedy are a cessation 
of the profuse flow, diminution in the length of the 
period, and in a measure curative of the disease. 

Borax is employed by some practitioners. (See under Ergota.) 

Caffea. In uterine hemorrhage Dr. Despres uses strong coffee, 
of which he makes his patients take four or five cups 
daily. He attributes to it properties analogous to those 
of ergot, and employs it under the same conditions. 

* Cannabis Indica. Dr. Churchill, of Dublin, obtains from 
the tincture of Indian hemp, in doses of gtt. v.-x,, 
thrice daily, remarkable success in the treatment of 
menorrhagia and uterine hemorrhage. Dr. Thomas, 
of New York, pronounces it one of the best agents in 
this disease at our command. 

Catechu may be used in passive hemorrhage. (F. 73.) 

Cimicifuga. Dr. Ringer, of London, says this remedy will cer- 
tainly arrest menorrhagia, though he regards it as 
inferior in this affection to the bromide of potassium. 

Cinnamomum. is a grateful stomachic, and nearly always of value 
in uterine hemorrhages. It may be given as tincture 
or in the powder, 3j. at a dose. 

Digitalis is useful in menorrhagia and other forms of uterine 
hemorrhage, unconnected with organic disease. Dr. 
E. J. Tilt, of London, employs the following : 



MENORRHAGIA AND METRORRHAGIA. 91 

81. R. Tincturse digitalis, fgij. 

Acidi hydrocyanici diluti, ttlxxx. 

Morphise acetatis, gr. j. 

Aquam, ad f.^ vj. M. 

A dessertspoonful every two or three hours. 

Dr. W. H. Dickinson recommended the infusion 
ij.-iss. 

*Ergota, though not equally beneficial in all cases, is a useful 
remedy in menorrhagia. Dr. Waring-Ctjrran states 
[Medical Press, Nov. 17th, 1869,) that it proves most 
useful in that form of menorrhagia which occurs in 
women of a scrofulous habit, who suffer from consti- 
pated debility, and in whom leucorrhcea exists as a 
consequence of previous hemorrhage. He gives freshly 
prepared infusion of ergot and borax in menorrhagia 
from obstructive cardiac disease, in that associated with 
a diseased portal system, in that consequent upon a 
scorbutic state of the system, and in genuine menorrha- 
gia (i. e.j an increase of the catamenia, continuing for a 
lengthened period, and returning before the proper 
period, without organic lesion.) He finds it has little 
or no effect in menorrhagia dependent upon ulceration 
of the os, the presence of polypous growths or other 
tumors, or in that arising from retroflection of the 
uterus. Ergotin, subcutaneously, should not be neg- 
lected. Athill prescribes it in the form of infusion, 
and if symptoms of ovarian irritation exist adds bro- 
mide of potassium in full doses. If anaemic, ten drops 
of tincture of iron with three to five drops of solution 
of strychnia to each dose of ergot. The strychnia 
increases in a marked degree the action of the ergot. 

Ferrum. The preparations of iron should be given when there 
is defective assimilation and nutrition, but must not 
be exhibited in a routine manner. There are cases of 
menorrhagia associated with pallor and debility, where 
the usual compound of iron and extract of ergot is not 
so useful as a non-chalybeate treatment. In these 
cases it is not any imperfection in the process of blood 
manufacture which is to be remedied, for the blood is 
made rapidly and quickly, only to be lost at each 
menstrual period. It is here desirable rather to limit 
the rapidity of the blood formation, so that when the 



92 DISEASES OP THE OVARIES. 

severe vascular turgescence of the menstrual period 
comes, it will not find the blood-vessels too distended 
with blood. This will lead to diminished catamenial 
loss, and so the blood-waste will be economized. 

*Gallicum Acidum was much employed by the late Sir. J. Y. 
Simpson", of Edinburgh, in atonic menorrhagia. He 
gave it in doses of gr. x., xv. or xx. daily, and continued 
its use during the intervals, as well as the period of 
discharge. Dr. E. J. Tilt, of London, while testify- 
ing to its value as an astringent in many cases, finds 
that it often fails when the hemorrhage depends upon 
organic lesions. Dr. William Goodell gives it in 
doses of gr. xx.-xxx. every two hours, in syrup or 
molasses. Dr. T. H. Tanner prescribes : 

82. R • Acidi gallici, _ gr. xv.-xxv. 

Acidi sulphuric! aroniatici, rr\,xv.-xx. 

Tincturse cinnamomi, f-^ij- 

Aquam destillatam, q. s. ad f. % ss. M. 

For one dose. Mix with two or three tablespoonfuls of water, and 
take every few hours, in profuse menorrhagia, until the bleeding 
ceases. 

Dr. Atthill gives it with ergot, ten grains of each. 

Hamamelis has been recommended, in doses of a few drops of 
the fluid extract. Its virtues are questionable. 

* Ipecacuanha, in full emetic doses, is often productive of the 
best results. Under the use of gr. xx. of the powdered 
root, in the evening, followed by an acidulated draught 
in the morning, the discharge frequently ceases in 
twenty-four hours ; if a relapse occurs, a repetition of 
the emetic seldom fails to make the cure permanent. 
Dr. Tyler Smith thus explains its action in these 
cases : by its emetic power, it excites contraction of the 
abdominal muscles and compression of the uterus, 
which may, in turn, re-excite some amount of uterine 
reflex action ; but beyond this, it appears to have a 
special action upon the uterus, increasing its contractile 
power beyond what could be imagined to occur from 
the merely secondary effects of vomiting. Ipecacu- 
anha thus appears to influence the medulla oblongata 
and the lower medulla spinalis. This double action 



MENORRHAGIA AND METRORRHAGIA. 93 

upon the extrenieties of the spinal centre is very extra- 
ordinary. 
Krameria is particularly useful in menorrhagia occurring about 
the usual time of the cessation of the menses. Dr. 
Dewees employed the following formula : 

83. R. Extracti kraraeriae, gij. 

Pulveris rhei, 3 ss. 

Syrupi, q. s. M. 

Divide into forty pills, and order two thrice daily. 

Magnesia Sulphas is recommended by Dr. Graily Hewitt, 
of London, who found a mixture containing very small 
doses of this salt, with a little dilute sulphuric acid 
and syrup, very useful during the time of the catame- 
nial flow. 

Matico. The pounded leaves, made into a paste and introduced 
into the vagina, are said to arrest the hemorrhage, 
after the failure of a strong solution of nitrate of 
silver. 

Plumbi Acetas often succeeds in severe cases, when given in 
enema 



84. R . Plumbi acetatis, gr. xv.-xx. 

Tincturse opii, Tt\,xl. 

Mucilaginis, f-^ij- M. 

For enema. 



In mild cases, the internal administration of sugar 
of lead and opium is usually successful. Dr. Work- 
man, of Canada, gives it in doses of gr. xxx., re- 
peatedly. 
*Potassii Bromidum is a favorite remedy of Dr. Ringer, of 
London, who lays down the following rules for its 
administration in menorrhagia : If the loss of blood 
occurs only at the natural menstrual period, it will be 
sufficient to begin the medicine about a week before 
the discharge is expected ; and when this has for a 
time ceased, it should be discontinued till the next 
attack is about to begin. If, on the other hand, the 
loss of blood occurs every fortnight, or oftener, it 
should be given without any intermission, till the 



94 DISEASES OF THE OVAEIES. 

disease is well controlled ; and when the discharge has 
been brought to its right period and amount, a few 
doses should be given for a short time before each 
monthly period. It has less control over uterine hem- 
orrhage due to tumors of the uterus than ergot and 
other remedies. In ovarian menorrhagia, indicated by 
tenderness of the ovaries, Dr. Alfred Meadows has 
found no drug which possesses so great power as the 
bromide : 

85. R • Potassii bromidi, gr. xxx. 

Syrupi ferri bromidi, gj. M. 

This amount in water thrice daily. Locally a pessary containing 
conia, gr. j., atropia, gr. -j- 1 ^, in the vagina every night. (British 
Medical Journal, July 12th, 1879.) 

Potassii Chloras. This is a very valuable agent in all forms of 
the hemorrhagic diathesis, as is ably shown by Dr. 
Alexander Harkin. (Brit. Med. Jour., October 
30th, 1880.) He uses in menorrhagia from this cause : 

86. R . Potassii chloratis, ^ i. 

Aquae, 3j xx. M. 

One ounce three times a day. 



Often some tincture of the chloride of iron may 
advantageously be added to this. 

Quinice Sulphas. In malarious districts, full doses of quinia are 
often the only remedial means efficient or required 
in this form of hemorrhage. Dr. Barnes always uses 
it in hemorrhage from sub-involution, 

Savina. Phillips has derived great benefit from gtt. v.-x. of 
the tincture, in a tablespoonful of cold water every half 
hour, in menorrhagia. Aran considers it one of the 
most valuable agents in hemorrhage from an atonic 
condition of the uterus. 

Sclerotinicum Acidum. This derivative of ergot has been em- 
ployed by Dr. Stumpf. (JDeutches Archivfiir Klinische 
Medicin, Oct., 1879.) The dose employed varied 
from two to sixty centigrammes ; no symptom of 
poisoning was observed. The results obtained in the 
treatment of hemorrhages were such as to show that 



MENORRHAGIA AND METRORRHAGIA. 95 

sclerotinic acid may fairly be ranked as equal in thera- 
peutic value to the other preparations of the ergot of 
rye; bearing in mind the rapidity of its action, and its 
relative harmlessness when used hypoderrnically, it 
may be regarded as superior to ergotine. In three 
cases of profuse metrorrhagia, 8 to 20 centigrammes suf- 
ficed to arrest the discharge. Metrorrhagia, especially 
that due to chronic metritis, was more obstinate, 
though in some instances a rapid cure was effected ; 
3 to 4 injections were generally required, and in one case 
eighteen. 

Sodii Salicylas. Dr. A. Schott, (Volkmann's Klinische Bei- 
trage,^So. 161,") says of this substance: "The best 
results are obtained in cases of menorrhagia and con- 
gestions of the pelvic organs by salicylate of soda. It 
acts as an anti-pyretic and anti-hemorrhagic remedy. 
It is highly beneficial, especially where there is conges- 
tion, swelling, pain, and slight elevation of temperature. 
Where it causes slight nausea, it can be given per 
rectum, by means of a long rectal tube. An elastic 
catheter (male) and a glass syringe are sufficient for 
the purpose, and the patients can use it themselves. 
From fifteen to thirty grains of the remedy are admin- 
istered for this purpose every hour, until the bleeding 
stops; if it returns, renew the dose. In obstinate 
cases large doses ought to be used. It causes ringing 
in the ears and temporary deafness. Only in affections 
of the heart is its use contra-indicated. By this treat- 
ment menstruations that lasted twelve to thirteen days, 
with great pain, ceased on the second day. My expe- 
rience with this remedy extends over a period of several 
years. " 

Sulphuricum Acidum Dilutum is a favorite remedy with some. 

*Tannicum Acidum, alone or combined with a small portion of 
dilute nitric acid, has often the happiest effects. Dr. 
Kobeet Burns, of Philadelphia, employs : 

87. R . Acidi tannici, 

Zinci sulphatis, aa gj.^ 

Glycerinse, f-^ j. M. 

Wet cotton with this, and apply to the interior of the uterus. 



96 DISEASES OF THE OVARIES. 

Trebinthince Oleum. A prescription recommended by Dr. E. J. 
Tilt, is : 

88. R. 01 ei terebinthina?, f.Jss. 

Tincturae capsici, f. g ss. 

Tin cturse ergota?, f • o j • 

Tincturae lavandulse composite, i*. ^ i j . M. 

In cases of uterine hemorrhage, give from half a drachm to a drachm 
of this mixture in milk, after shaking the bottle. In severe flood- 
ing after parturition, from half an ounce to an ounce may be 
given in plenty of milk, with good results. 

Urtica. The nettle in infusion is a popular remedy. 

Viburnum Pruni folium is peculiarly applicable iu metrorrhagia 
depending wholly upon systemtic causes, as phthisis, 
diseases of the heart or liver, malaria, etc. It is also 
beneficial in that occurring at the menopause. 

Viscum Album. The mistletoe has been recently commended in 
menorrhagia by some observers. 

Zinci Oxidum is highly spoken of by Prof. A. E,. Simpson, of 
Edinburgh, in doses of gr. ij. thrice daily. 

Zinci Sulphas, in doses of gr. j.-ij. in pills, thrice daily, is often 
useful in the atonic forms of menorrhagia. 



VAGINAL INJECTIONS. 

Alumen. Dr. E. J. Tilt, of London, orders, in purely atonic 
cases of menorrhagia, the following vaginal injection:. 

89. R. Aluminis, sjj. 

Decocti quercus alba?, O j. . M. 

This injection is inadmissible if inflammatory symp- 
toms be present. 

Ferri Chloridi Tinctura, with equal parts of water, has been 
injected with success. 

Galla. Decoction of galls ( 1 j J-, aquae Oj.), daily injected into 
the vagina, warm or cold, according to the feelings of 
the patient, is occasionally useful. 

Quercus Alba. The decoction, with or without alum (3j e ad 
decocti Oj.), is a serviceable and safe vaginal injection 



MENORRHAGIA AND METRORRHAGIA. 97 

Sponge Tents. Dilatation of the cervix by sponge tents has been 
found by Dr. G. H. Lyman and other gynecologists 
greatly to reduce the flow of blood in numerous cases 
of metrorrhagia. (Amer. Gynecol. Trans., 1877.) He 
believes that the real cause of the persistent hem- 
orrhage is in many cases some peculiar condition of 
the 'cervix, which strangulates the circulation, the 
removal of which condition promptly arrests the flow. 

Heat. Vaginal injections of water as hot as it can be borne 
prove of great service in many cases. Rubber bags 
or bottles filled with hot water, or a hot tile, plate or 
brick wrapped in flannel, applied to the sacrum, are 
likewise efficient. Bags of sand or salt may be heated 
and applied in the same manner. They should in all 
cases be hot, and not merely warm. Dr. John Chap- 
man believes a temperature of 115° Fah. to be suffi- 
cient in nearly all cases. 

Hot Hand-baths. Prof. J. Quissac, of Montpellier, recommends 
as a successful revulsive in metrorrhagia, soaking the 
hands in hot water. (Therapeutique Medicale, 1879.) 

Cold may be applied by cloths or ice-bladders to the uterus, 
vulva, and thighs; or Chapman's ice-bags to the 
sacrum ; or by injections of ice-water into the rectum 
or vagina. Dr. T. G. Thomas recommends that cold 
drinks only should be used, and the ingestion of all 
warm fluids strictly forbidden. In obstinate cases a 
change of residence from a warm to a cold climate often 
accomplishes a great deal of good. A lump of ice 
inserted into the vagina was the only hemostatic em- 
ployed by Madame Recamier. Dr. L. S. Oppen- 
heimeir, of Louisville, speaks strongly in favor of 
the cold hip-bath. (Louisville Med. News, Aug. 3d, 
1878.) He says : " I have seen cases of metrorrhagia 
lasting for over a month, permanently cured by this 
method alone in a few days. The mode of adminis- 
tration of these baths is not that of an ordinary hip- 
bath, but differs in that the water must be en cow-ant 
The stream should be so gentle at first as not to be felt 
by the patient, and gradually increased in force. The 
whole bath should not last longer than two minutes 
on the first day, then upon each succeeding day the 
length of time increased one minute/' 



98 DISEASES OF THE OVAEIES. 



HYSTERIA 



Although hysteria is not absolutely confined to the female sex, 
its vast preponderance among them, and its very frequent, in 
fact almost invariable connection with some abnormal state of 
the reproductive system, renders it, for the most practical pur- 
poses, one of the diseases of women, and for that reason we shall 
treat of it here. 

PROF. AUSTIN FLINT, M. D., NEW YORK. 

Of medicinal agents, asafoetida and valerian stand first. The 
bromides may often be prescribed with advantage ; but they, like 
all narcotics and stimulants, must be continued for a short 
time only, as hysterical patients very easily drift into their 
habitual use. 

The removal of associated disorders of any kind is an im- 
portant part of the treatment. Especially should all ovarian and 
uterine diseases receive immediate attention. Ungratified sexual 
desire as a causative agency has been overrated ; over-indulgence 
in sexual pleasure is more often a cause than continence. The 
propriety of advocating matrimony is doubtful. A very large 
proportion of hysterical cases are anaemic, and ansemia promotes 
hysteria, as it does other neuroses. To effect a restoration of 
the normal state of the blood, is generally a prominent in- 
dication. 

The moral management of such cases always calls for the ex- 
ercise of delicacy, tact, and firmness. 

PROF. WILLIAM AITEIEN, M. D., EDINBURGH. 

The following directions are given by this author as to what 
may be done during a fit of hysteria : Everything tight about 
the patient's person should be loosened. The window should be 
opened and the cold air allowed to blow over her. The hori- 



HYSTEEIA. 99 

zontal posture on a bed or the floor should be secured. This 
being done, many modes of further proceeding may be followed. 
Bleeding is, in all cases, of doubtful efficacy. When the jaw is 
locked, the following enema (recommended by Dr. Wood) may 
be used : 

90. R. Asafoetidse, ^ij. 

A quae, O ss. * M. 

To be beaten up with the yolk of an egg. 

Or, what is still better, 

91. R. Olei terebinthinae, £3^ 

To be mixed with the yolk of an egg, and then addecTto half a pint of 
water. " - 

Another remedy is to fill the mouth with salt. But that which 
supersedes all others, and is unquestionably the best, is a good 
drenching with cold water. If the patient lie on the bed, the 
head should be drawn over its side, and a large quantity of water 
poured on it, from a considerable height, out of a pail, jug, or 
other large vessel, and directly over the mouth and nose of the 
patient, so as to stop her breathing and compel her to open her 
mouth. This practice is generally introduced into hospitals, and 
until it was adopted, it was not unusual to see three or four 
patients in hysteria in the same ward and at the same time. 
Under this practice, however, a hysterical case is rare, and the 
fit seldom occurs twice in the same person, and never becomes 
epidemic. 

DR. A. B. ARNOLD, OF BALTIMORE. 

This writer remarks (Med. and Surg. Rep., August, 1879,) 
that every physician has some favorite combination from this 
class of drugs, which the hysterical patient is recommended to 
keep on hand for emergencies. The following he has found to 
answer the purpose very well : 



100 DISEASES OF THE OYAEIES. 

92. R. Ext, valerian, fl., f.gj. 

Ext. sumbul. fl., f.^ ss. 

Tinct. castorei, f-o v J- 

Spt. ether chloric, 

Syr. aurant. cort., aa f . ^ iij. M. 
One teaspoonful, frequently repeated. 

THOMAS KING CHAMBERS, M. D., LONDON. 

93. R. Acidi muriatici diluti, f.^iss. 

Aquae calefactae, (95° F.) C xxx. M. 

For a bath. This tonic warm bath is to be used once a day, in order. to 
prepare the patient for a shower-bath twice a day. 

Shower-baths, in hysterical cases are highly recommended by 
Dr. C. The making up the mind to the shock of a cold shower- 
bath is a capital exercise of the will. Such baths have also a 
good influence by arterializing the cutaneous circulation, driving 
the venous blood home to the heart and lungs. 

Our author rings the changes upon the following prescriptions 
in the treatment of this disease : 

94. R . Pilulae asafoetida?, No. xxx. 
Three to be taken thrice daily. 

95. R . Spirius ammonia? foetidse, f. J iij. 
A teaspoonful in water three times a day. 

96. R . Tincturae castorei ammoniatae, 



Aquae foeniculi, 
A dessertspoonful in water thrice daily. 


aa f.^ij. 


M. 


97. R . Pilulae galbani composite, 
Two thrice daily. 


No. xxx. 




98. R . Zinci valerianatis, 
Syrupi, 


3J- 
q. s. 


M. 



Divide into twenty pills. One to be taken three times a day. 



PROF. FELIX VON NIEMEYER, M. D.. TUBINGEN. 

98. R . Auri et sodii chloridi, gr. v, 

Tragacanthae, 3J. 

Sacchari, q. s. M. 

Divide into forty pills. Order at first one of these pills to be taken an hour 



HYSTERIA. 101 

after dinner, and another an hour after supper. Afterwards order two pills 
to be taken at these hours, and gradually increase dose up to eight pills daily. 

Dr. N. speaks of this preparation as a nervine of great efficacy 
in hysteria. He has made use of it with signal effect in many 
cases where there was no indication for the local treatment of 
uterine disease, or else where the hysteric symptoms persisted, 
although the local uterine affection had been cured. 

DR. F. T. PORTER, OF DUBLIN, 

Has found {Dublin Journal of Medical Science, April, 1874,) the 
bromides to act most injuriously in hysterical cases, deranging 
digestion, weakening the heart, and retarding menstruation. He 
prefers the valerianates, hemlock, and lupulus. When there is 
spinal tenderness, he employs iron. When plethora is present, 
as evinced by increased temperature, vascular relaxation and 
contracted pupil, he considers belladonna a most efficacious 
remedy. 

DR. S. WEIR MITCHELL, OF PHILADELPHIA, 

Believes that mimetic hysteria can be cured almost unfailingly ; 
but to accomplish this the patient must be isolated from the cares 
and sympathy of home and placed in an institution under strict 
surveillance. 

Valerianate of zinc in twelve grain-doses thrice daily is a valu- 
able sedative. If there is marked ansemia, the patient should be 
put to bed and fattened by the use of massage, electricity, and 
excessive feeding. 

EDWARD JOHN TILT, M. D., LONDON. 

100. R. Tincturse castorei, f . ^ iij. 

Spiritus lavandulse compositi, f-.^vj. 

Aquam camphorae ad f.Jjvj. M. 

A tablespoonful two or three times a day when cerebral symptoms and hys- 
terical phenomena are marked. 



102 DISEASES OF THE OVARIES. 

The therapeutical indications in the treatment of hysteria are : 
1st. To blunt the sensitiveness of the nervous system by seda- 
tives and antispasmodics, and to strengthen it by metallic and 
other tonics, and by hygiene. 2d. To cure all diseases of the 
sexual organs, and save the nervous system from visceral irrita- 
tion, by good hygiene at menstrual periods; or by marriage, 
when the sexual organs crave their legitimate satisfaction. 

GERMAN FHARMACOPCEA. 

101. 1& . Tincturse asafoetidse, f. 3 iv. 

Tineturse castorei, f-3iij« 

Tincturse opii, f-5J» M. 

From fifteen to thirty drops, by the mouth or in enemata, twice or three 
times a day, in the hysterical attacks of dysmenorrhea. Bitter drinks and 
preparations of iron in the intervals of the attacks, if the patient be anaemic. 



RESUME OF REMEDIES. 

JEther. Nothing, according to Stille, so distinctly moderates 
the paroxysms of this disease as the inhalation of ether. 
Those who have found the spasms aggravated by a 
certain degree of etherization have not administered a 
sufficient quantity of the vapor. If persisted in, it 
would undoubtedly have put an end to the fit. 

Allium. The smell of bruised garlic will sometimes promptly 
terminate a hysterical paroxysm. 

Atropia. In hysterical trismus, nothing acts so well as hypo- 
dermic injections of this alkaloid. Full doses are 
required. 

Auri et Sodii Chloridum is prescribed by Dr. Niemeyer. 

(F. 98.) 

Aloes. The pill of aloes and asafcetida is very serviceable in the 
constipation of hysteria. 

^Ammonium. The carbonate, the aromatic spirits, the foetid 
spirit, the valerianate, and other preparations, are much 
used and of great value. 

Amhemis. A wineglassful of the infusion of chamomile may 
be given with advantage thrice daily. 



HYSTEEIA. 103 

* Asafoetida is a most valuable medicine in this disease- It may 
be given alone, or combined as directed in the follow- 
ing form : 

102. R. Tincturte asafoetiila?, 
Tinctura? castorei, 
Tinctura? Valeriana? amnio- 

niata?, aa f. gij. 

Aquae camphorre, f.^vij. M. 

Dose — One or two tablespoonfuls every hour. Asafoetida may 
also be given, in the form of an enema. (F. 101.) 

Aurantii Flores. Orange- flower water is much used and valued 
in France. It is an elegant stimulant and antispas- 
modic, in doses from one to two fluid ounces. 

Cajuputi Oleum internally is often of benefit. 

Camphora is a very serviceable remedy, either alone or in com- 
bination with asafoetida or opium. 

Cannabis Indica is sometimes useful. 

Chloroform inhalation is highly praised by Dr. Brown-Sequard 
and Dr. Graily Hewitt, in severe and prolonged 
hysterical paroxysms. Internally it may be given 
with ammonia or asafoetida. A liniment of chloro- 
form often speedily relieves hysterical pain in the side. 

Cupri Sulphas, in small doses, long continued, is recommended 
by Sir B. Brodie, in obstinate hysteria. 

Cusparia Co? J£x. The infusion is an eligible light tonic in 
hysteria. 

Ferrum is indicated in hysteria associated with anaemia. It 
may be given combined with valerian and other anti- 
spasmodics. 

Galbanum sometimes agrees better than asafoetida, and may pro- 
duce equally favorable results, particularly in cases 
associated with disordered uterine functions. A gal- 
banum plaster over the sacrum often affords relief. 

^Lavandula is sometimes an effectual remedy. 

Lupulin has been recommended in chronic hysteria, attended 
with morbid vigilance, in doses of ten grains every 
six hours. 

Moschus, in doses of gr. x.-xv. thrice daily, is a valuable remedy, 
particularly when the surface is pale and the pulse 
languid. 



104 DISEASES OF THE OVARIES. 

Potassii Bromidum is sometimes a useful sedative in hysteria. 

Its use was suggested in this disease by Sir C. Locock. 
Ruta. From two to five drops of the volatile oil, on sugar, is 

a popular remedy ; so also is the infusion of rue. 

* Santonin sometimes proves useful in revealing the true cause 

of the hysterical symptoms, viz., worms in the intesti- 
nal canal. 

*Spiritus JEtheins Nitrosi is often very effectual in relieving hys- 
terical spasms. 

Terebinthince Oleum, in enema, will often arrest a severe paroxysm 
when ordinary means fail. 

* Valeriana is a valuable remedy; it may be given both during 

the paroxysm and in the intervals. 

Zinci Oxidum is considered by Dr. Warixg-Currax as more 
efficacious in hysteria than the valerianate. 

Zinci Sulphas, in the dose of one grain, combined with extract 
of gentian, in pill, two or three times a day, is a 
valuable remedy in cases of hysteria depending upon 
debility. It will be found to agree better with many 
women than the preparations of iron, causing less irri- 
tation. 

Cathartics are to be administered if constipation exists, as it is 
important in hysteria to keep the bowels open. Aloes 
are indicated if there be torpor of the uterine system ; 
mercurials or podophyllin, if there be biliary derange- 
ment ; and salines, if there be plethora ; but active 
purgation is in no case advisable. 

EXTERNAL REMEDIES. 

* Shower-Baths are indispensable in the treatment of the paroxysms. 

(See pp. 99, 100.) 

Dry Capping at the nape of the neck, between the shoulders, or 
below the clavicles, during a paroxysm of hysteria, has 
been found, by Dr. Graves, to be attended with the 
best results. 

Electricity. Dr. Laycock advises the persevering and sys- 
tematic application of electro-galvanism to the abdo- 
minal and pelvic regions, in combination with the 
internal use of tar. 



CHLOROSIS. 105 

Emetics. An emetic of ipecacuanha, given when the paroxysm 
is impending, often prevents it. 

Frigus. The sudden application of cold to the surface of the 
body, in hysterical cases simulating death, will revive 
the signs of life. 

Manipulation. Professor Thierry, of the St. Pierre Hospital, 
Brussels, arrests hysterical paroxysm by what he calls 
"torsion of the abdominal walls." He grasps in his 
hands the entire walls of the abdomen, either in their 
bare state or covered with the chemise, and imparts to 
them a certain amount of torsion, which he gradually 
increases, and which he maintains until the paroxysm 
has passed away, and the woman is come entirely to 
herself. 



CHLOROSIS. 

This name, or that of green sickness, is given to the ansemic 
condition of young girls, associated with disordered menstrual 
function. The blood has an excess of fibrine, and undergoes 
some chemical change in its pigments which produces the green- 
ish hue of the skin, whence the disease has its name. Atten- 
tion to hygienic conditions, baths, nutritious food, regularity 
of the bowels, and judicious mental and physical exercise, are 
first in importance. 

DR. FREDERICK T. ROBERTS. 

This writer on Practice considers aloes the best form of ape- 
rient, either the extract, or as pil. aloes cum myrrhd. For the 
unpleasant sensations in the stomach, bismuth, with hydrocyanic 
acid, is particularly valuable. For the pain in the side often 
complained of, a belladonna plaster is usually efficacious. Iron 
is the great remedy ; and it is frequently desirable to change the 
form of the preparation from time to time. 



106 DISEASES OF THE OVARIES. 

PEOF. A. P. REID, OF MONTREAL. 

This writer (Canada Medical Record, 1875,) has adopted, with 
signal success, in uncomplicated chlorosis, the use of liquor 
potassce, gtt. x.-xv., in mucilage, thrice daily. It defibrinizes 
the blood, and often acts promptly for good where iron is of no 
avail. 

DR. BRETOXNEAU, FRANCE. 



103. R. Ferri redacti, gij. 
Quiniae sulphatis, 

Zingiberis pulveris, aa gr. vij. 

Extracti cinchona, J) j. 

Aloes socotrmae, gr. iij. M. 
Divide into fifty pills. One to five a day. These pills have the advan- 
tage of not causing constipation. 



DR. GAILLARD, PARIS. 

104. R . Ferri carbonatis, 

Extracti cinchonse, aa ^ijss. 

Extracti opii, gr. xv. M. 

Divide into one hundred pills. From two to four a day, principally at 
meal-time. 

When there is constipation, this formula ought to be modified 
as follows : 



105. R . Ferri carbonatis, 3 ij. 

Extracti cinchona?, 

Extracti rhei, aa % iss. 

Extracti opii, gr. xv. M. 

Divide into one hundred pills. To be taken as above. 



PROF. E. J. TILT, M. D., 

Believes that, in addition to the general treatment, we require 
some means of increasing ovarian energy. He directs the 
patient to wear during the day a bit of piline large enough to 
cover the ovarian regions, sprinkled with alcohol. 



CHLOROSIS. 107 

DR. LOMBE ATTHILL, OF DUBLIN 

Regards strychnia as of the highest value; he gives five drops 
of the liquor strychnia?, equal to I/24 of a grain of the alkaloid, 
gradually increased to ten drops, three times a day, or combined 
with tincture of perch loride of iron. Strychnia acts as a power- 
ful stimulus to the ovaries as well as a general tonic. When 
there is no anaemia, five drops of tincture of iodine, and five of 
solution of strychnia, are of great value. 

For the constipation, he uses two grains of sulphate of iron 
with a quarter or half a grain of extract of aloes, three times a 
day. This often acts like a charm. 

NEW YORK, 

Regards the indications as to remove the cause, cure the neurosis, 
repair damages ; then change of air, well-regulated open air ex- 
ercise, sea bathing; tonics, as arsenic, strychnine and quinine. 
The continuous electric current and general electrization often 
are beneficial. • 

For the anaemia he gives : 

106. R • Ferri vini amari, f. ^ vijss. 

Tr. nucis vomicae, f. 3 iv. 

Liq. potas. arsenit., f-^ij- M. 

A dessertspoonful in a glassful of water just after each meal 

GRAILY HEWITT, M. D., LONDON, 

Regards the accompanying dyspepsia as best treated by food/re- 
quently and in very small quantities for days together, and of the 
simplest character, avoiding solids. Ferruginous preparations 
are essential, but should be given in small doses, and are best in 
the form of mineral waters. 



In cases of females where their maladies were connected with 



108 DISEASES OF THE OVAEIES. 

anaemia, indicating the use of iron, this writer has been very- 
much pleased with the action of oxalate of iron, a preparation 
first brought to notice by Prof. Craig, of the Smithsonian Insti- 
tute. It is a light and tasteless powder, with nothing repulsive 
in its appearance or odor. It may be given as a powder to those 
patients who object to the pill form. The dose is gr. ij.-iij. He 
states that it is less liable to cause irritation or constipation of the 
bowels than other ferruginous preparations, and many patients 
who have asserted they could not take iron in any form, have 
taken this without difficulty. 

RESUME OF REMEDIES. 

Aloes. This is frequently very efficient. (See page 107.) 
Bismuthi Subnitras. Sir H. Marsh states (Medical Press, 
March 6th, 1867,) that in chlorosis, bismuth is an 
excellent substitute for iron, when the latter is not well 
borne. 

Cocculus Indians is recommended by Phillips in chlorosis with 
amenorrhoea. 

Ergot in five-grain doses, three or four times a day, is recom- 
mended by Churchill, in chlorosis and leucorrhcea. 

* Ferri Iodidum. In chlorosis, accompanied by much torpor of 
the system, Dr. Ashwell has found this salt particu- 
larly efficacious, in the following formula : 

107. R . Ferri iodidi, gr. xvj. 

Tincturse calumbae, f.^ j- 

Aqua?, f.Jvij. M. 

Take two tablespoonfuls twice a day. 

*Ferri Mistura Composita, Ferri Chloridi Tinctura, Ferri et 
Quiniaz Citras, Ferri Sulphas, and Ferri Vinum, are 
all excellent ferruginous preparations in chlorosis. 

Sir H. Marsh advises (Medical Press, March 6th, 
1867,) the following formulas : 



108. R . Liquoris ammonise citratis, 


f-^iij; 


Ferri et quiniae citratis, 


gr. vii.-xxiv. 


Syrupi, 


f.|j. 


Aquae, 


f.^iv. M. 


Two tablespoonfuls three times a day 





CHLOEOSIS. 109 

109. R . Ferri sulphatis, 

Aloes, N aa gr. ij. 

Pulveris cinnamomi, gr. v. M. 

For two pills, to be taken at dinner-time, and repeated at night if 
necessary. 

Sodii Biboras. Dr. Copland advises the following formula : 

110. R • Sodii biboratis, 9 ij. 

Sulphuris praecipitatse, gj. 

Mucilaginis acacise, q. s. M. 

Make twenty-four pills. Three to be taken three times daily. 

Nux Vomica. Dr. Copland has derived benefit in some obsti- 
nate cases of chlorosis from the following formula : 

111. R. Pilulse aloes cum myrrha, gij. 

Extracti nucis vomicae. gr. x. M. 

Thirty-six pills. Take one to two night and morning. 

Potassce Liquor will occasionally overcome persistent anaemia 
which has defied all other means. Dose, 3ss.-j., 
largely diluted, two or three times a day. 

[For the general treatment of Anaemia see further suggestions 
in Napheys* Medical Therapeutics, chapter VI.] 



110 DISEASES OF THE OVARIES. 



THE CLIMACTERIC EPOCH, OR THE CHANGE OF LIFE. 

PROF. ROBERT BARNES M. D., LONDON. 

This author remarks that in many cases the local and consti- 
tutional disorders which attend the menopause are numerous and 
severe. Among these may be enumerated uterine and vicarious 
hemorrhages, a peculiar occipital headache, convulsive seizures, 
as vertigo and epilepsy, despondency, irritability, and loss of 
mental power, and various nervous disorders. Djspepsia, colic, 
and excessive constipation are among the most common attend- 
ants. Hysteria and pseudocyesis are also frequent. 

The principles of treatment are primarily to regulate the secre- 
tions, and exact a strictly hygienic mode of life. If the abdo- 
men is large and the bowels distended with gas, a broad, well- 
fitting abdominal belt will give great relief. When the patient 
is plethoric and florid, the abstraction of eight or ten ounces of 
blood from the arm, or by half a dozen leeches behind the ears, 
or by cupping between the shoulders, will often be of signal 
service. As an alterative the acetate of ammonia is one of the 
best; it may be combined with colchicum or lithia if a gouty 
diathesis is suspected. A most valuable remedy is bromide of 
'potassium, gr. x.-xx., two or three times a day, to calm and regu- 
late the nervous centres. Quinine and strychnia are to be 
preferred as nerve tonics. To keep the bowels open the habitual 
use of laxative saline mineral waters is the most serviceable 
means. 

DR. G. E. SUSSDORF, OF GERMANY. 

In speaking of the general rules for the treatment of disease 
at the change of life, this author makes the following points. 
{London Med. Record, Dec, 1878 ): 

1. The time of the menopause, as regards the inception and 



THE CLIMACTERIC EPOCH, OR THE CHANGE OF LIFE. Ill 

aggravation of disease, equals in importance that of puberty, or 
any other epoch of life. 

2. That while, as a rule, the majority of functional and organic 
diseases of the female generative organs decrease in intensity 
after the menopause, there is a considerable proportion of cases 
in which the reverse happens, even to the extent of the disease 
becoming malignant. 

3. In many instances these latter cases do not present decided 
local symptoms of the pathological conditions present, but are 
indicated by general signs, which attract attention because they 
occur at that particular time of life. 

4. In no case of general or local disorder, just before or 
during the menopause, should local examination be omitted, 
which will frequently reveal at a glance the origin of the 
hitherto inexplicable phenomena and also indicate the thera- 
peusis. 

5. Such therapeusis should be radical and effective, quite 
regardless of this particular time of life, the dangers of operating 
during which have been undoubtedly exaggerated. 

PROF. J. B. FONNSAGRIVES, OF MONTPELLIER. 

The indications of treatment for the complications of the men- 
opause are as follows (Traite de Therapeutique Appllquee. Paris, 
1878): 

1. To combat the condition of general and local plethora. No 
measure is so frequently successful as general bleeding, especi- 
ally from the foot ; or if the uterus is much congested, from the 
arm. The life should be active, the diet restricted, the sleep 
light, etc. 

2. To combat the menorrhagia. The two most efficacious drugs 
are ergot and the urtica urens, as : 

112. R. Ergotinse, 

Extracti matico, aa gr. xv. M. 

Make ten pills. Give one every one or two hours. 

The urtica urens may be given in decoction, § j. to aqua? O j., 



112 DISEASES OF THE OVAEIES. 

of which a wineglassful may be taken every hour or two. Cold 
batlis taken twice a day during the intermenstrual period are 
often of service. Cold vaginal injections also are beneficial. 

3. To combat the nervous complications. These must be treated 
in detail as they present themselves. An enlightened hygiene 
is all important. As a rule the use of alcoholics, spiced food, 
and venereal excitements should be prohibited. Dr. F. adds 
the advice, that after the permanent cessation of the menses, 
sexual approaches should absolutely cease, as they induce to the 
uterus a congestive afflux, which, useless for the function of 
reproduction, can only serve to cause various organic affections. 

PROF. FORDYCE BARKER, M. D., OF KEW YORK. 

In menorrhagia associated with the climacteric period, the 
uterus is generally found somewhat increased in size and weight. 
When such is the case, Dr. Barker directs the patient to use, 
for a week previous to the return of the expected period, rectal 
suppositories made after the following formula 

113. J& . Extracti ergotae aquosse (Squibb,) ^ ij. 

Butyri cocose, £j. M. 

Make twelve suppositories. Introduce one into the rectum morning, noon 
and night. 

They should be carried well up into the bowel, and the patient 
should lie down for an hour afterwards. 

Another plan of treatment, which is usually entirely success- 
ful if repeated for two menstrual returns, is to introduce into 
the cavity of the uterus cylinders of iodoform, made according 
to the following formula : 

114. R. Iodoformi, ^ijss. 

Gum tragacanthse, gr. xv. 

Mucilaginis, q. s. M. 

Divide into ten cylinders, each one and one-half inches in length. 

One of these is to be carried completely into the cavity of the 



THE CLIMACTEEIC EPOCH, OR THE CHANGE OF LIFE. 113 

uterus, and a pledget of cotton introduced against the cervix to 
retain it in position. One of these is to be introduced daily for 
five or six days before menstruation. The iodoform has an un- 
pleasant odor, but is the most efficient of all preparations which 
Dr. Barker has tried in these generally obstinate and trouble- 
some cases. 

KESUME OF EEMEDIES. 

Ammonice Acetas is considered by Dr. Barnes the best of the 

saline alteratives. 
Carbolicum Acidum. Dr. Bartlett, of New York (Buffalo 
Medical Journal, Sept., 1878,) places great confidence 
in carbolized sponge tents introduced within the cavity 
of the uterus. He has never seen ill effects, and has 
frequently controlled, by a single tent, climacteric 
hemorrhages which had resisted the ordinary tampon 
and various astringents. He introduces the tent 
through the speculum, well up to the fundus, and 
tampons over it in the usual way. 
Ergota is an invaluable drug in many cases. (F. 113.) 
Iodoform is very highly praised by Dr. Barker. (F. 114.) 
Matico is given internally by Prof. Fonnsagrives. (F. 112.) 
Sodii Bromidum. A writer in the Chicago Medical Journal, Jan., 
1880, states that the following prescription is specially 
serviceable in the various nervous manifestations which 
often accompany the menopause : 

115. R. 



Sodii bromidi, 


3 iv 


Tincturse nucis vomicae, 


f?ij- 


Elixir, calisayse, 


|y- 


Syrupi pruni virg., 




Elixir simplicis, 


3'vj. 



Sig.— Two drachms, two, three, or four times a day, as needed. 

Urtica. The various species of nettle have long enjoyed a repu- 
tation as efficient hemostatics in the hemorrhage of the 
critical epoch. Dr. W. B. Johnson, of Alabama, 
speaks highly of the urtica urens (New Orleans Medi- 
cal and Surgical Journal, vol. VI.,) and Prof. Fonn- 
sagrives gives the weight of authority in its favor. 
(P. 3.) 

8 



114 DISEASES OF THE OVAEIES. 

Purgatives. Mr. Lattsox Tait (Diseases of Wo- 
men, 1879,) says that for the relief of nearly all the 
subjective symptoms of the climacteric period, he 
knows nothing better than the occasional use of a 
drastic purgative, and removal from home at frequent 
intervals. They take the place of bleeding, which, in 
small amounts, gives in some cases immense relief. 
Permanent Cautery. It is taught by Prof. J. Quisac, of Mont- 
pellier, (Therapeutique Medicale, 1879,) that many of 
the troublesome symptoms which accompany the change 
of life can be avoided by establishing a permanent 
cautery or issue on the arm. This mode of treatment, 
now-a-days little employed, he believes will at times 
prevent the development of cancerous degeneration in 
tumors of the breast, and where these threaten, the 
establishment of an issue is formally indicated. 



CHAPTER II. 



DISEASES OF THE UTERUS AND ITS 
ANNEXES. 

Synopsis oj Diagnostic Points — Metritis (Non-puerperal Endo-, 
Peri-, and Parametritis, Uterine Catarrh, etc.) — Cervicitis 
(Ulcerations and Gramdations of the Os, etc.) — Displacements 
— Non-malignant Growths (Polypi, Fibroids, etc.) — Malignant 
Growths — Sterility and Anaphrodisia — Nymphomania. 

SYNOPSIS OF DIAGNOSTIC POINTS. 

GENERAL OBSERVATIONS. 

The most enlightened schools of modern gynecologists dis- 
countenance making gynecology a specialty, either in diagnosis 
or treatment. In other words, they insist on studying it as a 
department of general medicine. " There is, in truth," says 
Dr. Robert Barnes in a recent lecture (Lancet, May 25tb, 
1878,) " nothing more special in gynecology than there is in the 
study of heart disease, lung disease, or any other disease." And 
in the same spirit Prof. J. H. Etheridge, of Chicago, writes 
(Chicago Medical Journal and Examiner, November, 1878) : 
"Just so far as gynecologists can separate this so-called ' science' 
from the general science of medicine, will they obscure the mind 
of the ordinary practitioner with the error that gynecological 
cases need special care and skill, and are beyond the necessity 
for general prescribing." 

As general rules in the diagnosis of uterine disease, Dr. 
Barnes recommends that all the functions and organs be studied 
in a certain regular order, as follows : 

115 



116 DISEASES OF THE UTERUS AND ITS ANNEXES. 

(1) Aspect, plumpness, color and state of the skin generally. 

(2) The circulation, pulse, respiration, and temperature. 

(3) Nutrition, the tongue, appetite, digestion, stomach, intes- 
tines, defecation, and bile. 

(4) The urinary organs, the kidneys and bladder, as to pain, 
as to retention or other characters, as well as the characters of 
the urine itself. 

(5) The nervous system, sleep, motor power, general languor 
or exaltation, excito-motory system, mental state, delirium, pain, 
and its seat and kind. 

(6) The sexual organs, the menstrual functions, child-bearing, 
and the secretions. 

All these phenomena should be, as far as possible, explored 
by the aid of manipulation, and the appropriate instruments of 
exploration. It is a dangerous thing to form a subjective diag- 
nosis ; it is equally dangerous to accept the diagnosis from the 
patient. 

With regard to the special symptoms and signs which an ex- 
amination of the uterus and uterine functions may disclose, we 
quote from a lecture by Dr. Grail y Hewitt the following two 
lists the first (A) a list of the symptoms of all kinds which may 
be observed in connection with diseases or affections of the 
uterus, these symptoms being placed as nearly as possible in their 
order of frequency. The second (B) is a list of the various 
physical changes which the uterus may undergo : 

A. Uterine Symptoms. 

{1. Spontaneous. 
2. Produced by motion (dyskinesia.) 
3. Undue sensitiveness of uterus to touch. 
Leucorrhoea. 
Dysmenorrhea. 
Menorrhagia. 
Amenorrhoea. 

[If married — Sterility, abortions.] 
Various reflex phenomena : — 

1. Sickness or nausea. 

2. Hysteria. 

3. Convulsions. 

4. Cephalalgia. 

5. Melancholia. 



SYNOPSIS OF DIAGNOSTIC POINTS. 117 

Disturbance of functions of bladder. 
Disturbance of functions of rectum. 
Disturbance of sexual functions (dyspareunia.) 

B. Uterine Changes (non-organic.) 

Change in position. 
Change in size of walls. 

" " cavity. 

" " cervix. 

Change in shape. 
Change in patulency of canals. 
Change in texture. 
Undue hardness. 
Undue softness. 
Increased vascularity. 
Disorders of innervation. 
Increased secretion. 

Here, then, we have the data for the construction of a pathol- 
ogy of the uterus ; all the possible changes on one side, all the 
possible effects on the other. It must be understood that organic 
diseases of the uterus, cancer and fibroid tumor, are excluded 
from the list, the nature, course, and effects of these organic dis- 
eases being better understood. It must not, however, be forgot- 
ten that these organic diseases may occasion one or all of the 
uterine symptoms. 

UTERINE INFLAMMATIONS. 

Are usually divided into the acute and chronic forms of metritis, 
endometritis, cervicitis, and endocervicitis. The distinction has 
also been made between parametritis and perimetritis, and va- 
rious forms of inflammation of the os, granular, catarrhal, ul- 
cerative, etc. 

So far as treatment is concerned, in nearly all cases it is suffi- 
cient to distinguish between cervicitis, in which the os is alone 
or principally affected, and metritis, in which the body of the 
womb is also implicated. 

The distinctions which have been drawn between endometritis 
and endocervicitis, are compared by Dr. Etheridge on the fol- 
lowing page : 



118 



DISEASES OF THE UTERUS AM) ITS AXXEXES. 



1. Metritis. 



Acute. ( Very rare.) 



Chronic. 



a. Violent pelvic 
pain, accompanied 



Geue 

ral 

symp- with rectal, vesical, and 

toms. uterine tenesmus, and 
sometimes with nausea 
and vomiting. 

b. Pressure over ab- 
domen reveals great 
sensitiveness. 



2. Touch 



3. Spec- 
ulum. 



4. Probe 



a. Vagina hot and 
dry, unless, from co- 
existing endometritis, 
there be purulent dis- 
charge. 

b. Organ low in pel- 
vis, os enlarged, cervix 
swollen, pressure on 
cervix very painful. 

c. Painful tender- 
ness most . apparent 
upon rectal touch and 
conjoined manipula- 
tion. 

a. Usually produces 
too much pain to be 
used. 



a. Produces infoler- 



, a. Dull, heavy, drag- 
ging pain in pelvis, 
increased by locomo- 
tion. 

b. Defection and co- 
ition painful. 

c. Menses accompa- 
nied with pain, which 
begins several days 
previous. 

d. Pain in mamma; 
during and before 
menstruation. 

e. Darkening of are 
olae of the breast. 

/. Nausea and vom- 
iting. 

g. Great nervous dis- 
turbance. 

h. Pressure on rec 
turn, with hemorrhoids 
and tenesmus. 

i. Pressure on blad- 
der, with vesical tenes- 
mus. 

a. Enlargement. 

b. Tenderness. 



Nothing revealed 
specially. 



2. Cervicitis. 



Chronic. 



a. Pain i.n back and 
loins. 

b. Pressure on blad- 
der and rectum. 

c. Painful and some- 
times profuse menstru- 
ation. 

d. Difficulty of lo- 
comotion. 

e. Nervous disor- 
ders. 

/. Fain during sex- 
ual intercourse. 

g. Dyspepsia, head- 
ache, general lassitude 
and debility. 



a. Uterus low down. 

b. Cervix large, 
swollen, and painful, 
and os may admit fin- 
ger. 

c. Usually tender- 
ness. 



Confirms signs 
evinced bv touch. 



able pain, and cannot some flexion or ver- 
usually be resorted to 'sion, tenderness. 



a. Usually reveals Reveals great sensi- 



tiveness before reach- 
ing os internum, but 
nothing bevond that. 



SYNOPSIS OF DIAGNOSTIC POINTS. 



119 



3. Endometritis. 



Chronic. 



4. Endocervicitis. 



Acute. 



Chronic. 



General a. Leucorrhoea : 
symp- streaked, glairy, and 
toms. bloody. 

b. Menstrual dis- 
orders. 

c. Pain in back, 
;groins and hypogas- 
trium. 

d. Nervous disor- 
ders. 

e. Tympanitis. 
/. Symptoms of 

pregnancy. 
g. Sterility. 



Touch, 



Specu- 
lum. 



Probe, 



a. Conjoined ma- 
nipulation reveals 
tenderness of fun- 
dus. 



a. Reveals 
ing special. 



noth- 



a. Dragging 
weight and pain in 
pelvis, pain in back, 
groin and thighs. 

b. Rectal and ves- 
ical tenesmus. 

c. Purulent dis- 
charge, sometimes 
bloody after 3 or 4 
days. 

d. Tympanitis and 
tender abdomen. 



a. Dragging sensation in 
the pelvis. 

b. Pain in back and loins 
increased by exercise. 

c. Profuse, irritating leu- 
corrhoea, like boiled starch. 

d. Menses, too scanty or 
vice versa, too frequent or 
vice versa. 

e. Nervous, irascible, 
moody, or even hysterical. 

/. Digestion impaired, 
ultimately spanaernia, some- 
times nausea, etc. . 



a. Vagina hot and a. Os in normal position, 
dry, or covered with may be enlarged, lips puffy 
above discharge. jor may be roughened. 

b. Os gaping, cer- J 6. Pain results from plac- 
vix swollen and ten- ing the finger under the 
der, body slightly cervix and pressing up- 
enlarged, whole or-, wards. 

gan lower in pelvis 1 
than normal. 



a. Cervix puffy, 
swollen and red, 
fluid exuding from 
os, either clear, al- 
buminous looking, 
muco-pus, or stringy 
and tenacious. 



a. Patulous os in- 
ternum. 

b. Uterine cavity 
prolonged. 

c. Tenderness.'a few drops of blood, 
Withdrawal fol-J 

lowed by blood. ' 



a. Great tender- 
ness throughout 
whole organ, and 
removal followed by 



a. Long, stringy, tough, 
tenacious mucus, difficult 
to remove, exuding from os. 

b. Cervix not usually en- 
larged, may be puffy and 
swollen and very red, as if 
ulcerated, due to removal 
of investing epithelium. 

a. Meets with obstruction 
at os internum. 

b. Does not produce pain 
by striking against the 
walls of the fundus, nor is 
its removal followed by 
blood or mucus. 



120 DISEASES OP THE UTERUS AND ITS ANNEXES. 

METRITIS (NON-PUERPERAL, ENDO- PERI-, AND PARA- 
METRITIS, UTERINE CATARRH, ETC.) 

PROF. WM. H. BYFORD, M. D., OF CHICAGO. 

The treatment of chronic inflammations of the uterus is di- 
vided into the general and local treatment. 

General Treatment. The patient must be placed under the 
best practicable hygienic and dietetic rules, and sexual congress 
forbidden during treatment. For the nervous prostration, fresh 
and cold air is one of the most valuable tonics. The patient 
should be in the open air as much as possible ; or if confined to 
the house, she should be well covered, and all the windows and 
doors of the room thrown open several times daily She should 
keep in open cold rooms ; and the use of stimulants, to which 
such cases are given, should be forbidden. For the nervous ex- 
citability, regular rest, exercise, and outdoor exposure, are the 
most efficacious means. Medicines, as a rule, are not well borne 
in these cases. Quinine, nux vomica, wild cherry and chamo- 
mile, are the best. Stimulants must be exhibited cautiously, and 
opium is generally not well borne. Nervous headache, insom- 
nia and neuralgic pains, are often greatly relieved by bromide 
of potassium in full doses (gr. xxx.-lx. every hour in abundance 
of water, until relieved). Anseinia and plethora, if present, 
must be appropriately met. Constipation is often present, and 
must be overcome by prompt attention to the desire of defeca- 
tion, by a full vegetable diet, especially fruits, and by drugs. Of 
the latter, sulphate of magnesia, 3 ij.-iv., may be given with 
some acid in the morning ; or gr. vj.-x. of blue mass may 
be given every fourth or fifth night, followed by Epsom salts in 
the morning. When, through long habit, the secretions of the 
intestines are scanty, and their coats atonic, a special tonic is 
called for. Simple and effective formulae are : 



METRITIS. 121 

116. R . Strychnine sulphatis. gr. j. 

Ferri sulphatis, gr. viij. 

Acidi sulphurici diluti, q. s. 

Aquae, f. g ij. M. 

For a solution. One teaspoonful three times a day after eating. 

117. R. Strychniae sulphatis, gr. j. 

Extracti rhei, £) iss. 

Sulphatis ferri, gr. x. M. 

For sixteen pills. One to be taken once, twice or three times a day, as may 
be necessary. 

118. R . Quiniae sulphatis, gr. j. 

Pulveris nucis vomicae, gr. v. M. 

For one pill. To be taken after each meal. 

These are our most valuable remedial agents. Massage is not 
unfrequently a valuable aid. (See Resume of Remedies for the 
method employed.) Cold water may be thrown into the rectum 
twice a day in small quantities, say f. J viij. Or a suppository 
may be used, as 

119. R . Extracti gentianae, 9 j. 

Butyri cocoae, q. s. M. 

For a rectal suppository. 

Quinine, gr. v., may be employed in a similar manner. 

As a means of relaxing the sphincter ani, and removing its 
irritability, we can sometimes employ with advantage an oint- 
ment of belladonna : 

120. R. Extracti belladonnae, gij. 

Unguenti simplicis, § j. M. 

Apply to the anus externally on going to bed at night. 

When the rectum is weak and becomes readily filled with 
accumulated faeces, this can in a measure be prevented by wear- 
ing an air or sponge pessary, which will press the rectum 
against the sacrum and thus reduce its capacity. 

Local Treatment. Of the local measures employed, baths may 
be first mentioned. Injections are internal baths. The most 
common bath is the sitz, or hip-bath. Where there is much 
pain, with little inflammatory action, this often affords great 



122 DISEASES OF THE UTERUS AND ITS ANNEXES. 

relief. In many cases the patient can advantageously introduce 
a speculum while in the bath, so that the medicated water can 
readily reach the uterus. That temperature should be chosen 
which is most comfortable to the patient. Vaginal injections are 
applicable to almost all cases of cervical inflammation. Dr. 
Byford condemns intra-uterine injections as dangerous. The 
quantity of simple injections should generally be large — from 
one to eight quarts. Astringent injections ought not to be used 
more often than twice a day, the rule being never to repeat so 
long as the vagina is dry from the preceding one. The temper- 
ature should be governed by the feelings of the patient. 

Anodyne, astringent and alterative suppositories, pessaries, 
and powders may be resorted to with profit in many instances. 
The " suppository syringe " will enable the patient to place oint- 
ment in contact with the uterus very conveniently. In using 
narcotics in the vagina, the proper dose is double that by the 
mouth. The vaginal mucous membrane absorbs much more 
slowly than that of the rectum. 

The local remedies mostly employed by Dr. B. are the various 
depletory measures, nitrate of silver, tannin, acid nitrate of mer- 
cury, nitric acid, and caustic potassa. 

Nitrate of silver he prefers in the solid form. It should be 
slowly and gently passed over the inflamed or ulcerated part. 
If we use no more force than is necessary to keep it in contact 
with the part, there is no danger of keeping it there too long. 
It can be applied about once in six days. If applied in solution 
it should be strong — one part to four of water. It is not so 
applicable in aged persons, and they are often made worse by it. 
Creosote or caustic potassa is better in these cases. It also 
sometimes causes such severe pain that a substitute must be 
found. 



Chronic Endometritis. This disease presents itself in two 
forms, requiring different treatment. 1. As it appears in women 
who have borne children; and 2, in nulliparae and virgins. 



METRITIS. 123 

In women who have borne children the os is patulous and the 
sound is readily introduced, although causing pain. The lips 
of the os are usually swollen and soft. An important prelimi- 
nary step in such cases is local depletion by puncturing the cervix. 
One or two punctures, one-eighth of an inch in depth, will gen- 
erally be followed by sufficiently free bleeding. To this should 
follow the application of strong caustics to the interior of the 
uterus. Dr. A. prefers nitric acid and the solid nitrate of silver. 
Nitric acid seldom causes any pain if properly applied, and it has 
a wonderful effect in bringing about a healthy condition of the 
mucous membrane. It is readily applied on cotton, through the 
author's platinum canula or similar instrument. Carbolic acid 
may also prove serviceable in mild cases. If vegetations on the 
endometrium exist, they should be removed with the curette 
before the caustic is applied. 

In virgins and women who have never been pregnant, endo- 
metritis is usually accompanied by an elongated, probably 
swollen and congested cervix uteri, with a very small os from 
which a clear and slightly viscid discharge exudes. Flexion of 
the fundus is also often present. In these cases the first indica- 
tion fe division of the cervix, so as to insure a free escape for the 
contents of the uterus. Often this procedure will be sufficient ; 
if it is not, we should have recourse to the subsequent treatment 
of the unhealthy mucous membrane by the application of car- 
bolic acid, or some similar agent. 

Dr. A. regards blisters as of great value in chronic metritis and 
endometritis, where local blood-letting does not relieve. He 
applies them of small size, about two inches in diameter, and 
repeats them at intervals of a few days, placing them alternately 
over the sacrum and over the pubes, or over the ovary, if that 
be the chief seat of pain. 

In debilitated patients the application of iodine is preferable 
to blisters, as it does not weaken so much. Its use must be con- 
tinued for weeks, and it is best to direct it to be rubbed in over 
a limited space only, and when that spot becomes tender, to apply 
it to an adjoining part. 



124 DISEASES OF THE UTERUS AND ITS ANNEXES. 

To relieve the distressing backache in these affections, Dr. A. 
recommends : 

121. R . Linimenti caniphorse comp., f. £ x. 

Tincturee aconiti. 

Chloroformi, aa f.^iij. M. 

For a liniment. 
Or, 

122. R . Unguenti veratrise, 

Unguenti potassii iodidi, Partes equales. M. 
For an ointment. 

Either of these is to be well rubbed in over the seat of pain. 

DR. L. PLAYFAIR, LONDON. 

This writer observes that in many long-standing cases of 
uterine catarrh it is vain to expect a permanent cure by any 
means which do not act directly on the seat of the disease, which 
is the lining membrane of the cavity of the uterus and cervical 
canal beyond the external os; accompanied, of course, with 
secondary morbid states of the body of the uterus and cervix, 
such as hypertrophy, congestion, etc. Rest, applications to the 
exterior of the cervix, and general treatment, will unquestion- 
ably cause a temporary improvement, but on a recurrence to the 
old habits of life all the old symptoms return. There are serious 
objections to intra-uterine injections, unless the os is first dilated 
with laminaria tents, as they are apt to bring on severe uterine 
colics. By means of fine probes of whalebone or flexible metal 
round which a thin film of fine cotton-wool is wrapped, altera- 
tive applications can readily be made to the interior of the 
uterus, without pain or danger. In the very numerous cases in 
which this plan of treatment has been carried out, in no single 
instance has anything but the greatest benefit accrued. It is no 
doubt advisable to select the cases judiciously, and where there 
is much uterine tenderness, intra-uterine treatment should be 
postponed until this has been diminished by rest, leeching, etc. ; 



METRITIS. 125 

but with proper precaution the treatment is perfectly safe. A 
concentrated solution of carbolic acid, eighty parts to twenty of 
icater, is used, and it acts so well that for a long time nothing 
else has been employed. After the first application, the dis- 
charge is sometimes increased, but after the second or third it is 
generally greatly diminished, and a single application is often 
sufficient to cure superficial erosions of the cervix. As a rule, 
there is no difficulty in passing the probes, as in the true uterine 
catarrh the os is invariably patulous. 

DR. L. DE SINETY, OF PARIS. 

Metritis. This author rejects the classification of metritis into 
internal and parenchymatous, believing that it is useless for prac- 
tical purposes. He also believes, contrary to many, that acute 
metritis is occasionally found in unmarried women. The treat- 
ment depends upon the stage of the disease. At the outset he 
recommends fifteen or twenty leeches to the abdomen, complete 
warm baths prolonged two or three hours or else ice-bags to the 
abdomen and opiates internally. Opium may also be employed 
profitably by rectal injections. In the early stages of the malady 
the speculum must not be used, but later it may be introduced 
and scarifications made on the os. This local bleeding may be 
repeated every third day, and it will often prevent the inflamma- 
tion from becoming chronic. 

When the disease is in its chronic stage iron and the bitters 
are nearly always required. Alcoholic tonics, however, are inju- 
rious, and sometimes iron aggravates the disease. For local treat- 
ment astringent injections are of little value ; nor have cauter- 
izations of the cervical cavity proved much better. Sometimes 
pencils of tannin and carbolic acid left to dissolve in the cervical 
canal have done well. 

123. R . Acidi carbolici crystal., gr. iv. 

Glycerinse, gtt. v. 

Acidi tannici, gji. 

Pulv. tragacanth, q. s. M. 

For pencils three centimetres long and three or four millimetres in diame- 
ter. 



Acidi carbolici cryst., 


gr. v. 


Alcoholis, 


gtt. X. 


Glycerinse, 


£3j. 


Acidi tannici, 


gr. xxx. 



126 DISEASES OF THE UTERUS AND ITS ANNEXES. 

Nevertheless, he prefers liquid caustics, especially chromic 
acid, which, with certain precautions, he claims presents great 
advantages in the treatment of uterine affections. He uses a 
solution of equal parts of crystallized chromic acid and distilled 
water. In the intervals between the periods of cauterization 
he advises daily dressings with tampons wet with the following 
mixture : 

124. R. 



M. 



In the hemorrhagic form of the disease digitalis, quinine and ergot 
have been recommended. None of these means has given satis- 
faction. It is better to cauterize the interior of the uterus with 
the solid caustic. After this operation the patient should keep 
her bed one or two days. 

In regard to intra-uterine injections, our author believes that 
they should be reserved for cases in which every other means 
have failed on account of the hemorrhages sometimes following 
them. 

Chronic Parenchymatous Metritis. In this variety Dr. Sinety 
believes that ergot is indicated in cases resulting from sub- 
involution after confinement. It may be employed either by 
the mouth or by subcutaneous injections of ergotine. Some- 
times this reduces hypertrophy of the uterus in a few weeks, 
but at other times fails entirely. Hydrotherapy renders very 
great service if carried out. Simple baths of an hour in dura- 
tion every day are often successful. Thermal waters have many 
advocates, but they must be directed with great caution, and the 
indications are by no means clear for their use. Generally 
speaking, uterine and vaginal douches should be avoided ; and 
weak alkaline waters preferred to others. 

Locally, scarifications of the os every four or five days are 
required at the outset, especially when the organ is red and in- 
jected. When it is pale, hard and resisting the actual cautery 



METKITIS. 127 

gives good results. This operation is not painful when properly 
performed. 

Various complications occur in this disease, such as pruritus 
vulvae, cystitis, dyspepsia, etc., which must be treated as they 
arise. Conjugal relations should be forbidden, and exercise 
enjoined. 

Uterine Dyspepsia. Among the complications of uterine in- 
flammation, dyspepsia is one of the more frequent. A writer 
in the Revue Med. Chirurgicale des Maladies des Femmes, Feb., 
1880, says that whatever be the form of it, is admirably treated 
in lymphatic temperaments by means of the bromurated tincture 
of iodine : 

125. R • Tr. iodinii, 1 grm. 

Potass, bromidi, 4 " 

Syr. tolutani, 300 " M, 

A dessertspoonful before each meal. 

In the strumous it is better to employ the iodurated tincture. 
In arthritic subjects, sulphur with magnesia is that to which 
we should give the preference : 

126. R . Sulphur, sublimati, 2 grm. 

Magnes. calcinatse, 4 " M. 

For ten powders. 

The solution of arseniate of soda, one to ten tnousand, should 
be used in the dyspepsia of those of herpetic diathesis, affected 
with uterine diseases : 

127. R . Sodii arseniati, 10 centigrm. 

Aquae fontani, 1 litre. M. 

A dessertspoonful in the middle of each meal. 

The constipation which is generally present in these cases, 
should be combated at the same time. 

Perimetritis or I* elm-peritonitis. The treatment will vary 
with the intensity of the attack and the stage at which it has 



128 DISEASES OF THE UTERUS AND ITS ANNEXES. 

arrived. About one-half the cases of this disease follow child- 
birth. 

During the early acute stage a dozen leeches should be placed 
on the abdomen ; remission from pain should be secured by full 
doses of opiates, with which may advantageously be combined 
small doses of calomel (one or one and one-quarter grains hourly 
for five to ten hours.) An ointment of belladonna and mercury 
may be applied to the abdomen. Warm poultices, injections 
and baths are valuable. The rectum should be emptied. 

The acute symptoms having subsided, the next indication is 
to attack the organized products of the inflammation. In spite 
of the criticisms upon them, Dr. De S. employs scarifications of 
the neck. Leeches to the spot and flying blisters on the abdo- 
men are also efficient. Iodine ointment, and the introduction 
daily into the vagina of masses of charpie wet with a ten per 
cent, solution of iodide of potash, are both efficient. Fifteen to 
thirty grains of the iodide may be administered daily by the 
mouth, providing it does not induce gastric troubles. The gen- 
eral health must be supported by iron and hydrotherapic treat- 
ment. The following alkaline bath is especially valuable when 
all pain has disappeared : 



M. 



Two symptoms require special measures. One is a tendency 
to vomiting. This should be met by suspending drinks, giving 
small pieces of ice, and establishing a blister the size of half a 
dollar on the epigastrium, which should be dressed twice daily 
with a fourth of a grain of morphia. The second is swelling 
(ballonnement) of the abdomen. This can be reduced by ice 
poultices, or ordinary poultices sprinkled with camphorated oil. 

The most difficult question to decide is the proper time for 
surgical interference. In general, it is best to leave to nature 
prevalent collections arising from perimetritis ; those authors 



128. R. 


Sodii carbonatis, 


I iij 




Potassii iodidi, 


3vi. 




Aquae, 


q. s. 


For a bath. 







METEITIS. 129 

who recommend incisions have confounded this complaint with 
abscess of the broad ligament. In true peritoneal phlegmasia 
it is best to let the pus evacuate itself. 

The regular rectum of the menses is the most positive sign of 
a complete cure. 



In a paper in the Bii^mingham Medical Review, June, 1880, 
speaks of that form of subacute endometritis which occurs in 
weak, ill-nourished women after child-birth : 

Until a recent date astringent vaginal injections were the only 
means employed for the cure of such cases ; but when the use 
of the speculum became fashionable, so did the use of the 
nitrate of silver application to the cervix uteri. Still more 
recently, intra-uterine cauterization has become the favorite 
method. But all of these methods the writer holds to be in the 
main most unsatisfactory. The plan which he advocates, and 
which he has found much less disappointing, is, first, to improve 
the general health and give tone to the nervous system ; secondly, 
to rest and soothe the irritated periphery by the intra-uterine ap- 
plication of anodynes, especially of morphia and belladonna. 
Where there is much thickening, local scarification and the 
glycerine tampon are used, and if aching continue after acute 
symptoms have subsided, blistering over the sacrum is recom- 
mended. Mechanical and functional rest, so far as possible, are 
also enjoined. The chief internal remedies employed are phos- 
phorus, iron, and sometimes strychnia and bromide of potassium. 
The point of a Playfair's probe may be smeared with soft ex- 
tract of belladonna and passed into the womb, and allowed to 
remain there a few seconds; or morphia may be used in the 
same manner by taking up one-third or one-half a grain on the 
point of a moistened probe or sound. Belladonna plasters on 
the sacrum, opiate suppositories, the glycerine tampon, local 
scarification, all prove occasionally useful. When much aching 
remains after the acute symptoms have disappeared, a blister 
over the sacrum will generally remove it. 

9 



130 DISEASES OF THE UTERUS AND ITS ANNEXES. 

PROF. ROBERT BARNES, M. D., LONDON, 

In cases of simple metritis, applies twelve to twenty leeches 
above the pubes. A plasma consisting of one drachm of extract 
of belladonna, mixed with half an ounce of mild blue ointment, 
and two ounces of simple cerate, spread thinly on lint and 
applied to the hypogastrium, the whole covered with cotton 
wool, will give ease and subdue the inflammation. Tepid vagi- 
nal irrigations with water or decoction of poppy heads, or with 
laudanum, are useful. One grain of calomel with half a graiu 
of opium may be given every six hours for a day or two, taking 
care iy)t to salivate. Next salines, especially the acetate of am- 
monia, and nitrate of potassa, with sedatives, are useful. When 
there is septic infection, avoid leeches. Use the plasma as 
above, and salines combined with quinine and tonics. Offensive 
discharges are to be corrected by intra-uterine injections of per- 
manganate of potassa in carbolic acid. 

In the chronic form, it is important to aid the womb in 
throwing off its congestion, and hence support by a proper pes- 
sary is very useful. Warmth is of great service, as by heated 
bags of salt or bran, or water to the hypogastrium, or even the 
whole, or hip-bath, at 90° to 95° F. Free access must be given 
for the warm water to the vagina, by the use of the bath speculum. 
Irrigation may be employed, as the use of the patent syringe to 
play upon the cervix for fifteen or twenty minutes at a time. 
The general treatment must be tonic. 

PROF. T. GAILLARD THOMAS, NEW YORK, 

Insists upon perfect rest in bed. He applies warm poultices in 
towels wrung out of hot water to the hypogastrium, and covered 
with oil-silk. The patient should be kept under the moderate 
use of opium. 

In chronic cervical endometritis, he relies upon general regi- 
men, as the removal of depressing influences, etc. ; vegetable 
tonics, mineral acids and iron ; appropriate diet, but no stimu- 



METKITIS. 131 

lation; fresh air and exercise. As a tonic and cathartic he 
gives : 

129. R. Magnesise sulphatis, 3 ij. 

Ferri sulphatis, gr. xvj. 

Ac. sulph. dil., f . ^ j . 

Aquae, Oj. M. 

Two tablespoonfuls in a tumbler of iced water daily on rising. 

Or, 

130. R . Sodii et potassii tart., 3* ij. 

Yini ferri amari, f.^ ij. 

Ac. tartarici, fl .^ iij. 

Aquae, f.^xiv. M 
Two tablespoonfuls as above. 

If necessary, the draught may be repeated during the day. 
As a digestive tonic, he gives : 

131. R . One rennet washed and chopped, 

Sherry wine, O j. 

Macerate for twelve days, decant, 

filter, and add 
Ac. muriat. dilut., 

Tr. nucis vom., aa f.^ij. 

Bismuthi subnit., 3 ij. M. 
One teaspoonful in a quarter of a tumbler of water, before each meal. 

Emollient Applications. Irrigations for twenty or thirty 
minutes of the cervix night and morning by warm water, with 
the addition of salt, glycerine, boiled starch, infusion of linseed, 
slippery-elm, or tincture of opium. 

Alterative Applications. First, dilatation of the cervix. The 
surface having been thoroughly cleansed, it should be well 
painted with a saturated solution of copper, zinc or lead. Next 
a bit of cotton with a piece of stout thread attached, dipped in 
glycerine, should be applied to the cervix. This treatment may 
be repeated once a week. 

Or applications may be made by means of the probe wrapped 
with cotton, which is then saturated with the solution to be em- 
ployed. 



132 DISEASES OF THE UTERUS AND ITS ANNEXES. 

LAWSON TAIT, F. R. C. S., BIRMINGHAM. 

The treatment of chronic metritis consists most essentially in 
absolute rest in bed during the menstruation, and total suspen- 
tion of marital life. For medicines there is nothing like bromide 
of potassium and ergot, and there is nothing so had as iron. No 
matter how anaemic the patient is, iron should not be given until 
the uterine condition is cured, after which, indeed, it will often 
work marvels. Intra -uterine remedies are powerful adjuvants. 
Desiccated sulphate of zinc, carbolic acid, and even nitric acid, 
may be used. Where the chronic metritis is the result of an 
acute process, very great caution must be observed in applying 
any intra-uterine medication, lest the original mischief be re- 
excited. 

Acute Endometritis is nearly always the result of gonorrhoeal 
infection. Its characteristic signs are severe pain, some fever, 
tenderness of the uterus, and a profuse yellow purulent discharge 
from the os. The treatment is rest in bed, pessaries of lead and 
opium, hot fomentations over the abdomen, or even a blister, 
with general antiphlogistic measure j . Both vaginal and intra- 
uterine injections are to be sedulously avoided. 

Parametritis often occurs in the first few months of wedded 
life. Its treatment is by absolute rest in bed, with opiates and 
warm fomentations or poultices. If the tumor can be felt from 
the vagina, it should be tapped as soon as the indications of pus 
are clear. 

PHILADELPHIA HOSPITAL. 

Perimetritis. As regards internal remedies, one -twenty-fourth 
of a grain of the bichloride of mercury, with ten grains of the 
muriate of ammonia, are given three times each day in the mist, 
glycyrrh. comp. A pessary of cotton is constructed, which can 
be so adjusted as to hold the womb up. This cotton is dipped 
in a solution containing three-quarters of a grain of morphia to 
the drachm of glycerine. The morphia allays the pain and 
reduces the inflammation, and the glycerine usually sets up a 





f.^ss. 


aa f. 3 ij. 
i.ad f.^vj. 



METRITIS. 133 

copious watery discharge from the vagina. Iron is not em- 
ployed until late in the progress of the disease. 

After the inflammation is subdued, the patient is put upon 
the following mixture : 

132. R . Hydrarg. chloridi corros,. 

Liq. chloridi arsenitis, 
Mist, ferri chloridi, 
Acid, muriat. dil., 
Syrupi, 

Aquain, q. s. adf.gyj. M. 

SiG. One tablespoonful after each meal. 

DR. ROBERT BATTEY, OF ROME, GEORGIA. 

This writer has found of excellent effect what he denominates 
idodized phenol (American Practitioner, Feb., 1877.) 

133. R. Iodinii, % ss. 

Acidi carbolic! crystal., ^j. M. 

Combine by gentle heat. 

This is an energetic escharotic and alterative, and may be 
used, applied on lint or cotton, to cancerous surfaces. But for 
metritis, chronic affections of the cervix, hypertrophy, and sub- 
involution, he takes the following : 

134. R . Phenol iod. _ (F. ), % iss. 

Acidi carbolici crystal., Jf j. 

Aquse, f.^ij, M. 

Make a solution. 

This is to be used either of full strength or diluted with 
glycerine, to one-half, one- third, or one-fourth, according to the 
nature and requirements of the case. It is applied on cotton, 
the interior of the canal and uterus being mopped out (after the 
dilatation of the inner os), with the fluid. 

Dr. Battey uses a slender, elastic, hard-rubber probe, and de- 
scribes the preparation, use and effects of the application in the 
following language : 

" From the cotton factory is obtained cotton-wool in the form 
of an untwisted rope or coil, the fibres of the cotton being per- 



134 DISEASES OF THE UTERUS AND ITS ANNEXES. 

fectly straight and lying parallel to each other. This is techni- 
cally known to cotton-spinners as 'the lap/ and is admirably 
suited for gynecological uses. Having selected six or eight of 
the elastic probes, I break off from the cotton i lap ; four or five 
inches, and, with my fingers, separate or split it into several fas- 
ciculi of such sizes as, when wound on the probes, will enlarge 
them to the thickness desired. The end of a probe is now 
slightly moistened, and the fasciculus of cotton wound spirally 
upon it. The cotton-armed probe is dipped into iodized phenol; 
any redundancy is allowed to drip away, and the probe is 
passed into the uterus with a slow spiral movement as it ad- 
vances. At first it is introduced but a short distance, and imme- 
diately withdrawn, and the case rests here to test the tolerance 
by the uterus of the remedy. At subsequent stages the probe 
may be carried to the fundus, and followed immediately by a 
second, and even by a third or fourth, if well borne. The re- 
mainder of the wrapped probes are employed for wiping off the 
cervix or vaginal wall any of the phenol that may have touched 
these parts. The energy of the application is regulated by the 
size of the wrapping, the depth to which the probe is passed, 
and the number of medicated probes used. When a very de- 
cided impression is to be made, a backward turn is given to the 
probe on its withdrawal, so as to leave the saturated cotton in the 
uterus, there to remain twenty-four hours, or even until it is 
spontaneously expelled. The application is renewed every four 
to fourteen days, according to the energy of the treatment. I 
have abandoned the use of sponge-tents in connection with the 
treatment set forth. When dilatation is required, the cotton- 
wrapped probe is employed, and the cotton left as a soft tent in 
the canal. The dilating power of this is notably less than that 
of sponge, but nearly equal to that of sea-tangle, and it is be- 
lieved to be entirely safe. 

"The tesults are the following: 1. A perfect removal of all 
cervical mucus, which is promptly coagulated, and comes away 
closely adhering to the cotton. The probes subsequently passed 
bring the remedy directly in contact with the diseased surface. 
2. Always comparative, and usually entire, freedom from pain. 



METRITIS. 135 

Carbolic acid is a local anaesthetic, and so numbs sensibility as to 
make the energetic application of the iodine for the most part 
entirely devoid of pain. 3. The iodine is so rapidly absorbed 
that the patient ordinarily remarks the metallic taste in five or 
ten minutes. 4. Softening and more or less dilatation of the 
cervix and os. 5. Temporary arrest of leucorrhoea, followed by 
(6) watery and sometimes bloody discharge. 7. Exfoliation of 
the superficial layer of the mucous membrane, which comes 
away in shreds, sometimes entirely, and resembles glove-kid. 8. 
Abrasions of the os promptly heal. 9. Induration of the ute- 
rus soon disappears. 10. Leucorrhcea is permanently arrested. 
11. Villosities of the endometrium are removed without resort 
to the curette. 12. Subinvolution of the uterus disappears. 13. 
The menses become regular and healthy ; menorrhagia and 
scanty menstruation as well as dysmenorrhcea, are remedied. 14. 
The appetite and digestion are improved, and this often without 
the use of medicines. 15. The form of the cervix and os is 
often completely changed ; a large puffy cervix, with patulous, 
slit-like os, becomes even virginal in type after long use of the 
remedy. 16. Stenosis has not in any case been noted to follow 
the treatment. 17. Barrenness of from nine to fourteen years' 
duration has been removed in several instances." 

DR. H. V. TALIAFERRO, OF ATLANTA, GEORGIA. 

Pressure in Uterine Diseases. This practitioner has brought 
prominently to notice the application of pressure in diseases of 
the uterus, especially in the forms of chronic metritis (Trans. 
Med. Assoc, Ga. f 1878.) The pressure is exerted by filling the 
vagina firmly with well-prepared cotton or sheep's wool, in the 
manner of a tampon. 

In commencing the use of this tampon, the vagina should not 
be entirely filled. It is better to fill first the upper portion of the 
canal, which may be done quite tightly, and gradually to en- 
croach upon the entire canal as it becomes inured to the # foreign 
substance. Not unfreauently the tampon will irritate the vagina 



136 DISEASES OF THE UTERUS AND ITS ANNEXES. 

in the commencement of treating by its use, when it should be 
left off for a day or two, and hot water injections substituted. 
Tf, however, there be but little irritation, the use of a little sim- 
ple cerate, or better, vasaline, upon the vaginal surface, will 
enable us to continue the tampon. 

He is convinced that in this method we have a remedy for the 
rapid reduction of chronic congestions of the part, superior to 
any other. In adhesions of the uterus, with inflammatory de- 
posits, however extensive, its patient and persistent use is abso- 
lutely curative. 

INTRA-UTERINE MEDICATION. 

This is applied in the various forms of injections, pledgets, 
ointments, pessaries, crayons or pencils, capsules and powders. 

UTERINE INJECTIONS. 

Prof. Carl Schroeder, of Berlin, recommends the follow- 
ing cautions in the use of uterine injections : 

1. They should be avoided where there is marked tenderness 
or inflammation of the uterus or its appendages. 

2. There must be a free exit of the injected fluid ; hence it is 
better first to dilate, in every case, the uterine neck. 

3. Only a small quantity of fluid must be injected. 

4. The fluid should be slightly warmed, and slowly injected. 

5. Where there is flexion of the uterus, it is advisable to draw 
the fluid back into the syringe after a minute or two. 

Of substances used, probably the solutions of alum and iodine 
are the most useful, and these do not form precipitates with the 
albumen of the discharge, as iron, acetate of lead, nitrate of 
silver, etc. 

The safety of uterine injections has been much debated of late 
years, and is doubted by Drs. T. G. Thomas and Paul F. 
Muntxe,, of New York, and others ; but the tendency now is to 
consider them as without risk, if not too violent, and performed 
with all necessary precautions, especially that the internal os or 



METRITIS. 137 

cervix be fully dilated. Nevertheless, it is true that the French 
writers (Gallard, Leblond, Guichard, etc.,) reject this dil- 
atation as not necessary. 

A sense of heat, some pain, and a slight febrile movement, 
often follow an intra-uterine injection, and continue some hours. 
Should these symptoms not disappear, an anodyne poultice 
should be laid over the abdomen, and a moderate dose of opium 
or morphine be given. 

Contra-indications. Any acute inflammation in or near the 
uterus is a positive contra-indication against the use of intra- 
uterine injections. Hence where there is cystitis, ovaritis, or 
perimetritis in an acute form, we must not have recourse to this 
means. It is also advised on similar grounds to avoid this form 
of medication during the menstrual epoch, and for a week before 
and after the period. 

A marked uterine flexion is also held to be a contra-indication, 
inasmuch as the fallopian tubes may be so displaced and dilated 
that the fluid may easily find its way into the peritoneum, giving 
rise to serious results. 

Medicated Injections. One of the most successful agents in 
intra-uterine medication is "Dr. Churchill's tincture of 
iodine/' According to the formula given by that author in 
1864, it is made as follows : 

135. R . Iodinii, gr. lxxv. 

Potassi iodidi, % iss. 

Alcoholis, 3jj. M. 

This is used with great advantage as a stimulant, alterative, 
counter-irritant, caustic, and hemostatic. It has been very ex- 
tensively employed in the New York State Women's Hospital. 
The internal os is thoroughly dilated, and the instrument used 
for injection is an ordinary hard rubber uterine syringe. The 
patient is strictly enjoined to keep her bed for a week after the 
injection. In chronic endometral disease, and after the removal 
of fibroids, etc., its action is exceedingly beneficial. 

Dr. E. J. Tilt considers iodine the safest agent to inject into 



138 DISEASES OF THE UTERUS AND ITS ANNEXES. 

the uterus. He recommends the employment of a one-ounce 
india-rubber bottle with a pointed nozzle, fitting tightly into the 
end of a female catheter. The principal formulas he employs 
are: 

136. R. Tincturse iodinii, 

Aquae destillatee, aa f-^j- M. 

[ 

137. R . Liquoris ferri subsulphatis, f. % v. 

Aquse destillatee, . f. % iv. M. 

138. R. Ferri perchloridi, gij. 

Sodii bicarbonatis, gr. x. 

Aqua? destillatae, f. :§ iv. M. 

139. R. Acidi chrornici. gij. 

Aquae destillatee, £<|j« M. 

As a vehicle, glycerine is preferred by some, as it flows more 
slowly, and thus exerts the action of the agent for a longer time 
upon the uterine walls. As it is somewhat harsh when applied 
pure, it should be diluted. Oil of sweet almonds may also be 
employed. Dr. Liebman uses : 

140. R . Tincturse ferri perchloridi, 1 part. 

Glycerinae, 10 parts. M. 

Nitrate of silver should not be used for intra-uterine injections, 
as even in weak solutions it gives rise to violent uterine colics, 
often of long duration. 

The Swedes favor the sulphate of copper. Dr. Eckland, of 
Sweden, states that in the severer cases with ulcerations, hyper- 
trophy and neoplasms of the papillae, the best agent is sulphate 
of copper, with which, in dilute form, (1-5 to 1-50), this 
author has had extensive experience, applying it by means of an 
applicator to the entire interior of the uterus, it being very effi- 
cacious, without being followed by any inconvenience, such as 
erosion of the mucous membrane, which is produced by some of 
the other agents employed. 

Prof. James P. White, M. D., of Buffalo, in catarrhal me- 
tritis, prefers the following as a local application : 



METRITIS. 139 

141. R. Iodinii, gi. 

Potassii iodidi, 3 ss. 

Aciditannici, gj. 

Glycerine, q. s. to dissolve. 

Dr. W. W. Wilkens, of New Hampshire {Half-Yearly Com- 
pend.y 1876,) speaks very favorably of the following: 

142. R . Acidi carbolici crystal., 

Aquse. q. s. to dissolve. 

Glyceringe, aa equal parts. M. 

This mixture will not cauterize or destroy tissue. It may be applied to a 
mucous membrane without inflaming it ; but it will stimulate to healthy action 
one already inflamed. It should be applied to the entire mucous membrane 
of the womb every week or ten days. As a rule, no pain follows its use, and 
it never causes metritis or has other dangerous sequeloe. 

" LugoFs solution " of iodine in a concentrated form has been 
found efficacious by Dr. Joseph Kammerer. His formula is : 

143. R. Iodinii, 1 part. 

Potassii iodidi, 2 parts. 

Aqua?, 4 parts. M. 

Its use is chiefly indicated where catarrh of the uterus is com- 
bined with hypertrophy of tissue. 

Where the surface is eroded, with a tendency to hemorrhage, 
the same practitioner employs pyroligneous acid in its undiluted 
form, or else carbolic acid dissolved in an equal part of water. 
In those cases of hypersecretion where no erosions are visible, 
the following is a valuable astringent : 

144. R. Zinci sulphatis, gr. x. 

Aquas, f.|j. M. 



DR. 

Recommends the following method of intra-uterine injection, 
which is safe, and its general adoption might prevent many of 
the accidents now reported : Dr. Chadwick says: " Injections 
into the vagina should be made with, the patient lying upon her 



140 DISEASES OF THE UTERUS AND ITS ANNEXES. 

side until the fluid begins to ocze from the vulva ; the patient is 
then gradually turned upon her face while the injection into the 
vagina is continued ; by this plan the vagina is distended to its 
utmost, as in the knee and elbow position, while the uterus gravi- 
tates into the abdominal cavity and allows the fluid to flow 
through the patulous cervical canal into the cavity of the organ 
with the force of pneumatic pressure. Any air thus forced into 
the vagina by the syringe will remain in the vagina, and thus the 
possible danger of its passage into the uterine sinuses be avoided." 

PLEDGETS (PINCEAUX.) 

These are small masses of cotton, charpie, sponge, or other 
soft and porous substance, which are moistened with the medica- 
ted fluid and applied to the inner wall of the uterus. They are 
inserted by means of various instruments, as the " applicator " 
of Dr. H. E. Woodbury, of Washington, or that devised by 
Barnes. 

The liquids used in this manner are tincture of iodine, per chlo- 
ride of iron, solutions of nitrate of silver, nitric acid, iodoform, etc. 
The last-mentioned agent especially has given excellent results 
in the hands of a large number of practitioners, in the treatment 
of chronic endometritis. The slight pain which it produces 
and the rapidity of its effects make good its claim to be the most 
valuable of all applications in many cases of this malady 

The use of such pledgets is preferable to other means in the 
lighter forms of endometritis, where there is little or no hemor- 
rhage, where the intra-uterine area is small, dilatation slight or ab- 
sent, and the canal not tortuous. They should not be employed 
when inflammation is active, 

CRAYONS OR PENCILS. . 

These are inserted into the uterine cavity and allowed to re- 
main, the cervical canal being stopped by a plug of cotton. For 
example : 



METRITIS 141 

145. R. Iodoform!, S»ijss. 

Pulv. acacise, -1 

Mucilaginis, q. s. M. 

Divide into ten equal cylinders about one and a-half inches long. 

These pencils are hard, resisting, and capable of being divided 
into pieces of any length ; they should be preserved from light. 
They are used with advantage against superficial ulcerations of 
the uterus. They are introduced into the cavity and allowed 
to remain. 

Nitrate of silver* has been largely used in this manner. Re- 
camier introduced the solid nitrate into the body of the womb 
by means of Lallemand's porte caustique. Dr. Tilt prefers the 
porte caustique of Simpson, and leaves gr. v.-x. of the lunar 
stick to dissolve, provided the os be fully dilated. 

Prof. Pajot, (Annales de Gynecology, 1877, No. 21,) takes a 
laminaria tent two millimetres in diameter, dips it in thick 
mucilage, and then rolls it in finely powdered fused nitrate of 
silver, and allows it to dry. He thus obtains an elastic crayon 
of the ordinary size, which may be introduced into the uterus 
without fear of breaking. He believes this means to be appli- 
cable to other cavities, and for other more powerful caustics. 

The sulphate of zinc is also prepared in the form of crayons, 
twelve to fifteen centigrammes of the salt in each, for introduc- 
tion in this form into the uterus; it is recommended by Leb- 
lond, and is considered by Barnes one of the most useful 
agents in uterine catarrh. (See page 130.) 

Crayons of tannin have been used by some, but on account of 
their tendency to produce severe uterine colic and other accidents, 
they are not to be recommended. 

OINTMENTS AND GLYCEROLES. 

Dr. Eobert Barnes remarks (British Medical Journal, Janu- 
ary, 1873,) that a most precious way of applying almost any 
medicinal agent to the interior of the uterus is in the form of an 
ointment or plasma. They can be introduced bv means of a 



142 DISEASES OF THE UTERUS AND ITS ANNEXES. 

hollow sound, with a piston working in its centre, the " ointment 
positor." Where grease is objectionable, glycerine, cocoa butter, 
cosmoline, vaseline, etc., may be used. Thus bromine, iodine, 
mercury, etc., can be safely applied. 

In simple chronic endometritis, Dr. A. Leblond (Traite de 
Chirurgie Gynecologique, 1878,) has employed the following with 
excellent effect : 

146. R. Cerati simplicis, 20 grammes. 

Pulveris iodoformi, 

Olei amygdal. dulc, aa 5 grammes. M. 

In cold weather, the amount of oil should be increased. 

Glyceroles of starch, tannin, and other substances, may also 
be employed. 

147. R . Iodoformi, 1 part. 

Glycerins?, 10 parts. 

Olei menth. piper., q. s. M. 

The above glycerole of iodoform has been extensively used 
by Dr. E. H. Kisch. (Schmidt's Jahrbucher, Bd. 184.) He 
states that it actually stimulates the resorption of exsudates, 
alters favorably the secretion of the mucous membranes, and 
materially reduces excessive sensibility. The principal uses of it 
are in chronic metritis, chronic endometritis, and in old inflam- 
matory conditions of the pelvic peritoneum and cellular tissue. 
A piece of wadding is wet with the above solution, and inserted 
in the evening, up to and against the vaginal portion of the cer- 
vix, where it is allowed to remain till morning, when it is with- 
drawn. In addition to this, it may be rubbed into the inguinal 
and hypogastric regions. 

CAPSULES. 

The introduction into the uterine cavity of various medical 
substances enclosed in capsules has been suggested by Dr. E. P. 
Sale, of Aberdeen, Miss. (American Practitioner, June, 1875.) 
They may be made of gelatine, and introduced in the same 
manner as pledgets. 



METRITIS. 143 

POWDERS. 

The insufflation of powders of alum, tannin, calomel, iodo- 
form, etc., into the uterine cavity has been practiced by Prof. INT. 
Gueneau de Mussy and others. Several serious accidents have, 
however, resulted with most of these agents in this form, and 
except, perhaps, in the case of iodoform, there is no advantage, 
and an absence of safety in this plan of medication. 

PESSARIES, OR INTRA-UTERINE TENTS. 

These are usually of cotton, saturated with some medicated 
fluid, allowed to dry, and introduced by a probe or a positor. 
The internal os generally requires to be dilated before this can 
be done. A thread may be attached to the tent, by which it 
may be withdrawn after a few hours ; or, it may be allowed to 
remain until thrown off by the action of the uterus, which 
usually occurs within forty-eight hours (Battey.) 

KESUME OF EEMEDIES.. 

Acidum Carbolicum is used as a local application by Play- 
fair. (P. 125). 

Acidum Chromicum is advocated as a cauterant by Dr. Tilt 
(F. 139.) Its application to the uterus sometimes pro- 
duces the most severe vomiting, hence it is not very 
safe (Tait.) 

Acidum Nitricum is one of the most efficient local caustics in 
many cases. For introduction into the uterus it is 
probably the safest of the fluid caustics. (See page 
123.) The following method of using it is recom- 
mended by Dr. D. 1ST. Kinsman, as possessing advan- 
tages over any other [Obstetric Gazette, Nov., 1878) : A 
piece of white wax smoothed down to the requisite 
size to enter the cervical cavity and given the proper 
curve, is dipped into the acid ; a sufficient quantity 
adheres for the purpose to which it is to be applied. 
The wax bougie is grasped with a pair of dressing for- 
ceps and passed into the cervix ; applied in this man- 



144 DISEASES OF THE UTERUS AND ITS ANNEXES. 

ner there is no excess of acid to run over adjacent 
parts, while there is enough to act as a caustic or alter- 
ant. 

Argenti Nitras is preferred as a caustic by many physicians. 

Belladonna, internally, is recommended. (F. 120.) 

Boracicum Acidum has been suggested as a useful agent. 

Cupri Sulphas is used in Europe. 

Ferrum. The preparations of iron are used internally as tonics, 
and the tincture of the chloride locally. (F. 140.) 
Tait warns against iron in any form in chronic me- 
tritis. (See p. 132.) 

Iodinium in several forms is in use by nearly all practitioners 
(F. 136, 141.) In the treatment of parenchymatous me- 
tritis, M. Gallard gives iodine internally in almost 
every case — in quantities of from six to twelve drops 
of the tincture in mucilage, for eight or ten days every 
month, beginning, by preference, at the time when a 
menstrual flow ought to take place, for it succeeds best, 
he says, in cases accompanied with dysmenorrhcea or 
amenorrhoea. 

Iodoformum, although disagreeable to most patients, has been 
found an excellent application. (F. 145.) 

Tannicum Acidum is an astringent of great value. 

Veratria, in the form of ointment, is an efficient local anodyne. 
(F. 122.) 

Zinci Sulphas was applied in undiluted form to morbid uterine 
tissues by Simpson. Others have preferred it more or 
less diluted and made into sticks. 

EXTERNAL MEASURES. 

Blisters are highly commended by Dr. Atthill, (P. 123.) Dr. 
E. Park (Glasgow Med. Jour., Oct., 1880,) says that 
the most effectual way of treating chronic metritis is to 
apply blisters about the size of a crown piece to each 
iliac region alternately. 

Massage of the Uterus. This has been recommended in uterine 
atrophy, chronic metritis, and chronic uterine catarrh, 
by Prof. G. Asp, of Helsingford, (Schmidt's Jahr- 
Micher, Bd. 181,) and others. The proceeding, as 



METRITIS. 145 

stated by this writer, is as follows : The operator, with 
one or two fingers in the vagina, grasps the body of 
the uterus so that he can exert upon it a steady pres- 
sure, while the counter-pressure is exerted by the other 
hand through the walls of the lower abdomen. If 
these walls are sufficiently loose and enlarged, by this 
procedure the uterus can be held between the fingers 
of the two hands, and gently pressed and kneaded. 
When the organ is displaced, it is usually necessary to 
correct the displacement before this method can be ef- 
fectually used. 

The kind of cases, according to Dr. A. R. Jackson, 
of Chicago, in which it may prove useful is the follow- 
ing : When the uterus is low down, large, tender, 
spongy, doughy, etc. ; this condition is usually asso- 
ciated with hyperemia, and massage would be expe- 
dient unless contra-indicated by other circumstances. 
After the stage of hyperemia has passed, and that of 
induration has been reached, the uterus is still low in 
the pelvis, displaced and distorted usually, but the 
spongy feel has passed away, and massage will be found 
to be almost useless. 

There are three modes of performing the massage : 
1, through the abdominal walls ; 2, through the ab- 
dominal walls and the vagina; 3, through the abdom- 
inal walls and the rectum. The first is applicable in 
cases in which the vagina is small or unusually tender. 
The patient is placed upon her back, and at first the 
skin and superficial tissues are subjected, by means of 
the fingers, to alternate pinching and rubbing. After 
a few days the fingers can be depressed among the tis- 
sues so as to reach the uterus, which can be alternately 
squeezed and rubbed for from fifteen to thirty minutes 
in the gentlest manner possible. The preliminary ma- 
nipulation is advisable in all cases; in some it is abso- 
lutely necessary. 

In cases in which the uterus has not risen above the 
brim of the pelvis, the abdominovaginal method may 
be employed, with one or two fingers in the vagina 
and those of the opposite hand in the hypogastric re- 
gion. The last method is the least available, and must 
be limited to a small class of exceptional cases ; such 
as those in which the vagina is so small or tender as to 
make it impossible to adopt the second method. 
10 



146 DISEASES OP THE UTERUS AND ITS ANNEXES. 



CERVIATIS (ULCERATION AND GRANULATION OF 
THE OS.) 



This author defines as follows the varieties of ulceration of 
the os, and what he considers the very best methods of treating 
them. 

1. Indolent Ulcer. Cervix hypertrophied, of a pale pink color, 
and hard. Os patulous to a small extent. Ulcer of a rose red. 
Granulations large, flat, insensitive, and the edge of the ulcer 
sharply defined. Discharge : mucus, with a little pus, and occa- 
sionally a drop of blood. 

Treatment. For a few times the caustic pencil — solid nitrate 
of silver. Afterward, the solution of nitrate of silver in strong 
nitric acid. 

2. Inflamed Ulcer. Cervix tender, hard, a little hypertrophied, 
hot and red. Vagina hot and tender. Ulcer of a vivid red. 
Granulations small and bleeding. A livid red border around 
the. ulcer. Discharge: a rnuco-pus, yellow and viscid, with 
frequently a drop of bright-red blood entangled in it. 

Treatment. Occasional leeching, hip-bath (warm), emollient 
injections. Then acid nitrate of mercury several times, succeeded 
by the solid lunar caustic, potassa fusa, or cum calce. 

3. Fungous Ulcer. Cervix soft, large, spongy to the touch. 
Os wide open, so as to admit the finger. Ulcer large, pale, 
studded with large and friable granulations. Discharge : glairy, 
brownish mucus, frequently deeply tinged with blood. 

Treatment. At first, the caustic pencil. w Subsequently, nitric 
acid, solution of nitrate of silver, or acid nitrate of mercury ; 
electric, or actual cautery. 

4. Senile Ulcer. Cervix small, red, a little hard. Ulcer small, 
extremely sensitive, of a bright-red color. Granulations very 
small, red, and irritable. Discharge : a thin muco-pus. 

Treatment. Potassa fusa, or strong nitric acid, with nitrate of 



CEEVICITIS. 147 

silver once or twice at long intervals. The solid sulphate of 
copper, in pencil. 

5. Diptheritic Ulcer. Cervix of ordinary size, a little hot, dry, 
and tender. Ulcer covered in patches with a white membrane, 
adhering closely, irritable, and readily bleeding beneath. Dis- 
charge : a thin acrid mucus, without pus, but occasionally tinged 
with blood. 

Treatment. At first, electric cautery, potassa cum calce, or 
acid nitrate of mercury, two or three times at long intervals. 
No nitrate of silver. Subsequently, stimulating applications, 
tincture of iodine, or sulphate of copper. 



This writer states that {Traili Elementaire de Chirurgie Gyne- 
cologique, Paris, 1878,) the treatment of the os and cervix by 
means of cauterizing agents is so prominent that it deserves to 
fix our attention. The caustics employed are directed (1) to the 
surface of the os and cervix, or (2) to the parenchyma. They 
have also been classified as (1) mild, and (2) energetic caustics. 

In follicular ulceration of the surface of the os and cervix, a 
strong solution of nitrate of silver gives excellent results. The 
application produces a slight eschar, which is detached in five or 
six days, after which it may or may not be renewed. 

AVhen the ulcerated surface is red and softened with tumefac- 
tion of the cervix, the tincture of iodine is to be preferred on 
account of its resolvent properties ; or, what in some respects is 
better, iodoform, which is at once an energetic cicatrizant and a 
local anaesthetic. 

Bleeding ulcerations, with a varicose aspect, will be happily 
modified by a solution of perchloride of iron at 30°. It should 
be repeated at the close of five or six days. 

Obstinate ulcerations will sometimes yield in a satisfactory 
manner by application of a solution of hydrate of chloral. 

148. R. Chloral hydratis, 2 grammes. 

Aquae, 25 grammes. 

The ulceration to be touched daily with this for some time. 



148 DISEASES OF THE UTERUS AND ITS ANNEXES. 

When the ulcerations are swollen and fungous, a more potent 
caustic than those above mentioned is required. Scanzoxi used 
pyroligeneous acid; Dr. Gallard, crystallized acetic acid, or car- 
bolic acid. The first mentioned is the least painful. 

Pencils or crayons of nitrate of silver, sulphate of zinc, per- 
chloride of iron, iodoform, or other substances, may often be 
advantageously employed. Those of tannin are to be prepared 
as follows : 

149 H. Tannin, 1 gramme. 

Pure glycerine, q. s. 

Rub together and roll into two crayons each five centimetres in length. 

The most suitable formula for crayons of the other ingredients 
mentioned is the following : 

150. R. Sulphate of zinc (or other agent), 

Gelatine, aa 2J grammes. 

Pure glycerine, gtt. v. 

To make ten crayons of six centimetres each. Powder the gelatine and 

place in a capsule in a sand-bath. Add the glycerine and ten drops of water. 

Stir till melted and smooth. Add the zinc or other agent with a few drops of 

water if necessary. Mix carefully, then cool and mould rapidly into pencils. 

In certain cases where there is simply morbid enlargement of 
the os (as sometimes in chronic metritis) without ulceration, this 
engorgement may often be reduced by inserting some iodide of 
potassium enclosed in a tampon of wadding. Placed in contact 
with the neck, this substance generally produces a slight ulcera- 
tion which rapidly heals, and is followed by a diminution of the 
organ. After eight or ten days, it may be repeated. 

In cases of vegetations and rebellious ulcerations, more potent 
agents are required. Of these chromic acid is ranked by some 
as one of the best. It produces a dry, yellowish eschar. The 
crystals are used, being applied directly against the part, until 
the whole of it is covered with the eschar. It is not uncommon 
for this application to be followed by vomiting and diarrhoea, 
and precautions must be taken that as little of it as possible be 
absorbed into the system. 



CERVICITIS. 149 

Caustic potassa, Canquoin's paste, Vienna paste, and Filhos* 
caustic, are other powerful caustics occasionally applied. They 
should be used with great caution. Dr. Filhos' caustic is a solid 
form of Vienna paste, and is more manageable than it. Nitric 
acid is convenient of application, and has furnished good results. 
The acid nitrate of mercury is apt to extend beyond the deceased 
structures, and it is said to leave troublesome cicatrices. It has, 
however, been especially recommended in syphilitic ulcerations 
of the os. 

In that form of cervicitis accompanying chronic metritis, where 
the cervix is enlarged, infiltrated, softened, and generally more 
or less ulcerated, as well as in a later stage of the same morbid 
process, when the cervix is enlarged, thick and hardened, the 
actual cautery will usually furnish the best results. This may be 
applied as the hot iron, the thermo-cautery, the galvano-cautery, 
the gas-cautery, or the cauterizing pencils. The application of 
the red-hot iron is not at all painful. It is followed by an 
eschar which is detached after eight or ten days, leaving a 
healthy granulating surface, and is not followed by a contracting 
cicatrix. The iron should be nearly at a white heat in order to 
prevent the adherence of the tissues which takes place when it is 
at a dull red. 

Of the other methods of cautery mentioned, the cauterizing 
pencils of M. Bonxafoxd may be described. They are little 
cylinders made of powdered charcoal and nitre, as follows : 

151. R . Nitrate of potassa, 2 grammes. 

Powdered wood charcoal, 30 " 

Gum tragacantb, 10 " M. 

Or, as follows : 



152. R. Nitrate of silver, 1 gramme. 

Wood charcoal, 28 " 

Powdered acacia, 4 " 

Water, q. s. M. 

They are lighted at a candle and applied to the part ; but as 



150 DISEASES OF THE UTERUS AXD ITS ANNEXES. 

they are at once extinguished by the application, they are suita- 
ble only when superficial eschars are desired. 

Cauterization by ignipuncture has been advised in this form of 
cervicitis when very rebellious. Filiform cauteries are used, and 
are inserted into the tissues to the depth of four to eight milli- 
metres. Four to six punctures are made, distributed over the 
lips of the os. 

After the cautery has been applied, the vagina should be 
washed with cold water, and the patient keep her bed for the rest 
of the day. 

DR. T. GAILLARD THOMAS, NEW YORK. 

The cardinal point is to look upon the ulcer as a local mani- 
festation of diseased action in the cervix or body, which is the 
lesion to be treated. The ulcer is a symptom of a graver and 
more important morbid state, which must be kept in view. It 
often happens that one symptom of a disease so distresses the 
patient that the remedy must be addressed solely to it ; as when 
the ulcer by its profuse discharge calls for prompt relief. When 
the ulceration results from inflammation confined to that part of 
the cervical tissue immediately underlying it, the relief of the 
ulcer by the alterative and counter-irritant action of the means 
adopted, may effect the cure of the disease producing it, and the 
fact of the existence of such disease may not be recognized. 
" But when it depends upon the irritation of the discharges from 
the cavity of the cervix or the body of the uterus, or upon deep- 
seated areolar hyperplasia, cure is more difficult." 

Caustics will be quite sufficient for ordinary granular degenera- 
tion, but when there are exuberant development of villi, so- 
called cock's-comb granulations, it is well to snip these growths 
closely by a pair of long-handled scissors, or even to -scrape 
them off smoothly with a currette, and then apply the caustic. 
Of these, Richardson's styptic colloid is excellent. It is a direct 
alterative, and forms a protecting crust over the ulcer. 

Where there is eversion of the cervix, the hemorrhoidal mem- 



CEEVICITIS. 151 

brane may be removed as above, and the actual cautery, or the 
nitrate of silver applied. An excellent method of cauterizing 
these ulcers is the gas jet cautery of Acosta, of Paris. An 
ordinary rubber bag is filled with carburetted hydrogen from 
the gas jet; a blow-pipe is fitted to the end of a tube attached 
to the bag, the escape of the gas being prevented by pinching 
the tube. The bag is compressed, the gas ignited, and the tiny 
flame is applied through the speculum to the spot. 

After such treatment the patient is to be kept in bed, and the 
parts copiously irrigated two or three times a day ; glycerine, 
laudanum, or infusion of bran or linseed, may be used. In a 
week or ten days, according to the potency of the caustic, the 
slough has separated. If the surface appears healthy, the 
milder alteratives are to be employed, as a pledget of cotton, 
saturated with equal parts of glycerine and solution of subsul- 
phate of iron, or glycerine f. 3 vj. and tannic acid f. 3 ij. In 
addition, the patient should inject each night and morning a 
gallon of warm water, containing an ounce of glycerine and a 
drachm of sulphate of zinc; or two drachms of sulphate of 
alum, acetate of lead, or tannin, for ten or twenty minutes. 
Medicated suppositories may be used, of zinc oxide ; or sulphate 
of alum, gr. iij. ; or ung. hydrarg., gr. x. ; or plumbi iodidi, gr. 
v. ; or acid, tannic, gr. ij. And, as an anodyne, may be added to 
either of these: ext. belladonaa, gr.j.; or pulv. opii, gr. ss. 
These articles may be made into a mass with tragacanth, starch, 
slippery elm, and glycerine, and covered with cocoa butter. 

When needed, the caustics may be repeated, but not too fre- 
quently — time should be allowed for the development of their 
stimulant effect; once a fortnight or even once a month. 

In follicular ulcer, evacuate the cysts and cauterize their cavi- 
ties thoroughly by nitrate of silver, chromic acid, or the acid 
nitrate of mercury. 



152 DISEASES OF THE UTERUS AND ITS ANNEXES. 

PKOF. J. MATTHEWS DUNCAN, M. D.* 



This teacher is of opinion that what is popularly called 
" ulceration " is properly chronie catarrh of the cervix. In 
many slight cases, the mistake is made of ordering too strong 
vaginal injections or lotions. The following is more appro- 
priate : 

153. R . Plumbi acetatis, g ss. 

Aquas tepidas, % viij. M. 

For an injection to be thrown up every night by the patient herself. 

The same quantity of alum or zinc sulphate may be substi- 
tuted for the lead. Cauterization by introducing the nitrate of 
silver into the cervix and turning it around is the ordinary, but 
not the most successful treatment. 

In severe cases the best caustic is zinc-alum. Sticks of this, 
from one to one and a-half inches long, are made by fusing to- 
gether equal parts of sulphate of zinc and sulphate of alum, 
and running the mixture into moulds the size of a ISo. 6 or 7 
bougie. The cervix is exposed and a sound is passed to find if 
the passage is clear and to expose its direction. Then the stick 
of zinc alum is introduced and left in the vervix. A plug of 
cotton or lint is placed in the upper part of the vagina to keep 
the stick from coming out and to receive the caustic that dissolves. 
After three hours the plug is removed and the vagina well 
washed with tepid water. The caustic produces a yellowish- 
white slough, which after several days comes off, leaving in suc- 
cessful cases a surface which secretes healthy cervical mucus. 
This caustic is stronger than nitrate of silver. 

In the severest cases still stronger caustics are required. The 
best is caustic potash applied so as to produce a slough in the 
thicker hypertrophied lip. Sometimes the actual cautery proves 
very efficacious. 

It is advisable not to go on treating indefinitely an obstinate 
case of chronic catarrh. If after two or three trials, each of 

* Lectures on Diseases of Women, 1880. 



CERVICITIS. 153 

which may extend over several weeks, a cure is not effected, it 
is better to give up further meddling with the matter. 

DR. L. DE SINETY. 

Ulcerations depending on metritis sometimes rapidly disap- 
pear under the influence of scarifications alone. Generally, 
however, topical treatment is necessary. In the choice of agents 
the phase of the disease is to be considered. During the con- 
gestive period nitrate of silver often acts injuriously. Dr. De 
Sinety prefers crystallized chromic acid diluted with an equal 
amount of water and used as follows : Carry the acid to the 
point to be cauterized on a little cotton fastened to the end of a 
small piece of wood. Take care that the quantity of the liquid 
is just sufficient not to flow beyond the space on which it is to 
act and immediately after applying it give a full injection of 
water to remove any that remains. Other useful agents are per- 
chloride of iron, tincture of iodine, iodoform, tannin, alum, 
chloral and creosote, as in the following formulas : 

154. R . Chloral hydratis, 9j. 

Aquse, |j. M. 

Touch the ulcerations daily with this. 

155.. H. Glycerinse, gvj. 

Alcoholis, ^iij- 

Creosoti, gtt. xv. M. 



In that common form of enlargement of the vaginal portion of 
the uterus, with thickening, tumidity, redness, and often superficial 
ulceration of the lips surrounding the os tincse, together with 
engorgement and enlargement of the muciparous follicles, just 
within the neck, and pouring out, as they always do in this con- 
dition, profuse secretion, or exudation, popularly called " whites " 
or fluor albus — this practitioner (Monograph, 1880,) 'never ap- 
plies nitrate of silver, but has, times without number, carried a 



154 DISEASES OF THE UTERUS AND ITS ANNEXES. 

large bougie up to the fundus of the uterus, allowing it to 
remain in the cervical canal twelve, sixteen, or twenty-four 
hours, and generally with more satisfactory results than from 
any other single expedient, topical or general. The relief is 
attributed to overcoming contraction in the fibres of the con- 
strictor cervicis muscle, releasing the venous circulation, and 
thereby preventing retardation of blood and consequent engorge- 
ment. The original and continued cause having been removed 
by the bougie, he generally relieves existing engorgement by 
giving one or two Brancard's pills of iodide of iron after each 
meal; and when syrup of the iodide of iron can be had with- 
out free iodine in it the following may be substituted for the 
pills : 

156. R • Syr. ferri iodidi, % iiss. 

Aquse fol. aurantii, % iiiss. M. 

Sig. — A teaspoonful after each meal, in water. 

The muciparous follicies, he says, existing just within the os 
tincse, and occupying the walls of the cervical canal for about 
an inch, are the sole and only sources of fluor albus. These 
follicles are often found enlarged and tumid, without other 
engorgement or trouble of any sort, in the tissues surrounding 
them. Signal relief is often derived from introducing a bougie 
and allowing it to remain a sufficient length of time in the cer- 
vical canal, thereby releasing the veins, and allowing their return 
circulation to pass through them unimpeded. The obstruction 
to venous flow being thus relieved, existing engorgement in the 
muciparous follicles may be resolved by giving the following : 

157. R. Hvpophosphit. sodse, 

Hypophosphit. calcis, aa ^iij. 

Hypophosphoric acid, q. s. ad sat. 
Aquse destillaise, 5j vi. M. 

Sig. — Give a teaspoonful after each meal. 

Pure phosphate of lime in the magma form is much better to 
prescribe in doses of ten grains, thrice daily, provided we can be 
sure of having it furnished in proper assimilable form by the 
apothecary. 



CERVICITIS. 155 



The first step in the more acute forms of inflammation of the 
cervix is to relieve the congestion by puncturing the cervix. 
The point of the knife should penetrate from one-eighth to one- 
quarter of an inch. When the lining membrane of the cervix 
is extensively implicated, the next step is to apply strong nitric 
acid freely to the whole interior of the cervical canal. The 
acid is introduced on cotton wrapped around a platinum probe, 
and care must be exercised that it does not touch the walls of 
the vagina. This may be followed after a few days by the 
g 7 ycerole of tannin, applied in a similar manner; or the glycerole 
may be used instead of the acid. 

158. & . Acidi tannici, gr. x. 

Glycerinse, f.^j. M. 

Thoroughly saturate a pledget of cotton with this, and then 
attaching a piece of string to facilitate its removal, introduce it 
up to the os uteri through the speculum, and leave it there for 
twenty-four hours. This is often productive of great benefit. 
If much irritation exists in the vagina, omit the tannin and use 
plain glycerine. 

When the cervix is greatly engorged, oedematous, and covered 
with papillae, sometimes the above procedures fail, and nothing 
promises relief but the total destruction of the diseased surface 
by caustic potash. Whenever this caustic is used, it should be 
applied through a glass speculum, and rubbed freely against the 
part; a pledget of cotton saturated in vinegar should be pre- 
viously inserted between the lower lips of the os uteri and the 
edge of the speculum, so as to neutralize any of the potash 
which may escape; and the vagina should be washed out with 
vinegar immediately after the application. The patient should 
remain in bed several days. When much induration exists, the 
potash may have to be applied several times. 

Milder applications are nitrate of silver and tincture of iodine. 



156 DISEASES OF THE UTERUS AND ITS ANNEXES. 

The latter seems to allay the backache so much complained of 
in these affections. 

DR. W. 0. DABXEY 

Writes in the American Journal of the Med,. Sciences, July, 1879, 
of the topical use of ergot : 

" Although it is mentioned now in nearly all the works on 
gynecology, its value does not seem to be recognized by the ma- 
jority of general practitioners. It appears to be especially ap- 
plicable in cervical metritis. The manner in which it should be 
applied depends on the season of the year and the temperature. 
When the weather is sufficiently cool suppositories are preferable, 
but in warm weather it is difficult to handle them and keep 
them from melting. The addition of extract of belladonna 
increases the efficacy of the ergot, and also tends to relieve any 
pain which may be present. The following formula I have 
found serviceable : 



"159. R. Ergotine (or solid extract of ergot), gr. xx. 
Extract of belladonna, gr. ij. 

Cocoa butter, q. s. M. 

" Make into six suppositories, and insert into the vagina every night after 
using the hot douche. 

" In warm weather a solution of ergotine and extract of bel- 
ladonna in glycerine and water may be used in place of the sup- 
positories, as in the following formula : 

"160. R. Ergotine (or Squibb's solid extract,) gss. 
Extract of belladonna, gr. vj. 

Water and glycerine, aa f.^iv. M. 

" A pledget of cotton is to be saturated with this solution, and inserted into 
the vagina at bed-time after the hot douche. (The cotton should, of course, 
be removed in the morning.) 

" It has been proposed to paint a solution of ergot on the os 
and cervix with a camel's-hair pencil, and favorable reports of 
this mode of treatment have been published. So far as my own 



CEEVICITIS. 157 

experience enables me to judge, those cases where there is a co- 
pious discharge of mucus or pus are much less amenable to treat- 
ment than others, and this is probably due to the fact that the 
medicine remains in contact with the diseased surface such a 
short time before it is washed off. And I would call attention 
just here to the advantages of glycerine over water as a vehicle 
when ergot is applied to mucous membranes where it is liable to 
be speedily washed off. The tenacious properties of glycerine 
keep the remedy longer in contact with the diseased surface, and 
in addition to this the glycerine itself is, as Dr. Marion Sims 
long ago pointed out, of decided value in reducing some of these 
chronic inflammatory engorgements." 

J. P. THOMAS, M. D., OF KENTUCKY. 

This writer (Richmond and Louisville Medical Journal, Sept., 
1879,) describes a medicated pessary, partaking of the emollient 
and soothing effects of a poultice, which he has used with suc- 
cess in erosions of the os and cervix uteri, and of neighboring 
parts of the vaginal surface. It is based on a formula of Dr. 
Rezin Thompson, and is as follows : 

161. R . Pulv. ulmi corticis, 1 fb. 

Pulv. ipecac, et opii, % iij. 

Bismuthi snbnitratis, % ij. 

Pulv. sassafras rad. cort., % iv. 

Balsami eopaibse, £ iv. M. 

The powders are to be intimately mixed by passing them suf- 
ficiently often through a gauze sifter. The copaiba is to be 
thoroughly incorporated with the powder, and water gradually 
added until the mass, by constant working or kneading acquires 
the consistency of stiff dough ; then roll into balls from one to 
two inches in diameter, according to the desired size or shape of 
the pessary. When the balls are perfectly round, place them on 
a smooth board in the sun, or if cloudy, under a stove, to par- 
tially dry. When they begin to feel hard, moisten them slightly 
and smooth and close any cracks that may have formed, and after 



158 DISEASES OF THE UTERUS AND ITS ANNEXES 

a few hours manipulate them, into any form desired. Before 
introducing them they should be dipped in warm water. 

The actual cautery, either the hot iron or charcoal pencils 
(F. 151), are also valuable aids in obstinate cases. Iodized cotton 
may be introduced into the cervix as recommended by Dr. 
Greenhalgh. 

DR. KCEBERLE. 

In the Annates de la Societe de Medecine de Gand, M. 
Kceberle prefers chromic acid as a cauterizing agent to the 
other remedies usually used, as pernitrate of mercury, iodine, 
nitrate of silver, and the actual cautery. He uses it in the crys- 
talloid condition. It is a very anhydrous substance, and readily 
absorbs the moisture from the tissues which it may touch. M. 
Kceberle applies it through an india-rubber speculum on a 
tampon of cotton wool. Vomiting often supervenes within 
fifteen or twenty minutes from the application of the acid. 
When the tissues are seriously altered, it is necessary to repeat 
the cauterization, but M. Kceberle has hitherto found three 
applications to suffice. After the application he applies a tam- 
pon, and advises the patient to use two soap-and-water injections 
daily. He treats all ulcerations of the os in this way, as in 
epithelioma. 

DR. ROBERT BELL, OF GLASGOW. 

This writer, in the Lancet^ Aug. 10th, 1878, describes a very 
successful and simple mode of treatment of those cases of papil- 
lary ulceration of the cervix, in which, on examination, the va- 
ginal mucous membrane is found to be turgid and red, and un- 
duly sensitive to the touch. The vaginal portion of the uterus 
is hypertrophied, and around the os the finger detects a spongi- 
ness of the mucous membrane, and the lips are everted. On 
introducing the sound, hemorrhage to a small extent is induced. 
The uterine canal measures three inches. The speculum reveals 
a granular ulcer extending both outwardly and inwardly from 
the external os. This has evidently been due, in the first place, 



CEEVICITIS. # 159 

to erosion of the papillse, which, by continued irritation, has 
developed into this granular condition. The slightest touch 
causes it to bleed very freely. 

The treatment commonly employed in such a case is the uter- 
ine douche night and morning, which the patient uses herself, 
while an application twice a week of a moderately strong solu- 
tion of nitrate of silver is made by the physician. 

Dr. Bell finds he can effect a cure in half of the time by 
another method. All the discharge is wiped away by means of 
cotton- wool, and then pure tar is applied to the diseased surface 
on a pledget of cotton. This is allowed to remain in contact 
with the ulcerated part for twenty-four hours at least, when the 
patient withdraws the cotton by means of a piece of string which 
has been left for the purpose. The application is made twice a 
week, and in from two weeks to a month the cure is complete. 
The tar is made fluid by the addition of one part of rectified 
spirits to eight parts of pure tar. This application has another 
great advantage besides its healing properties : it acts as an ano- 
dyne ; and then a further benefit is derived from the support 
which the pledget of cotton-wool gives to the enlarged uterus. 

DE. EOBEETS, MANCHESTER, ENGLAND. 

In ulceration of the os, this writer, while commending the car- 
bolic application, does not consider the strong acid necessary in 
superficial ulceration. A mixture of one part of the strong 
acid with two of olive oil seems to answer all ordinary purposes ; 
but in cases of very deep ulceration the use of the strong acid 
may be called for. In such cases, Dr. Roberts desires the acid 
to be liquefied by the addition of a very small quantity of 
water. This has not been found always to answer the purpose, 
but it has been noted that the addition of a few grains of cam- 
phor will dissolve the acid, and will, moreover, prevent it again 
becoming solidified, even at a freezing temperature. The appli- 
cation of the carbolic oil to the os uteri is best effected by soak- 
ing a little cotton-wool in the liquid, securing it by a string, and 



160 DISEASES OF THE UTERUS AXD ITS ANNEXES. 

introducing it through a speculum, the string being left depend- 
ing out of the vagina, and the patient being directed to pull it 
away on the second day. This procedure is repeated in ordinary 
cases about twice every week. If it be desired to apply the 
acid to the cervical canal, it may readily be done by passing in a 
gum-elastic catheter smeared with the carbolic oil. 

DR. J. M. BEXXETT, OF LIVERPOOL. 

Interstitial Injection. In chronic cervical metritis (enlarged 
os, inflammatory enlargement and induration of the os,) this 
writer [lancet, Nov. 2d, 1878,) has tried with gratifying results 
the interstitial injection of iodine. 

lie first prepares the patient both generally and locally ; the 
latter by relieving any super-engorgement by means of local 
depletion, carried out by means of cupping, the frequent use of 
warm water, and the application of glycerine, so as to induce 
osmotic action, care being taken to avoid the period of menstrual 
excitement. He then uses a simple modification of the hypoder- 
mic syringe, which is sufficiently long to be used with Ferguson's 
speculum ; its points are made of eighteen-carat gold ; and the 
other portion, which might come in contact w T ith the iodine, 
bromine, or other agent inimical to any metal less resistant than 
gold or platinum, is mercurially gilt. The instrument should 
be charged with a solution composed as follows : 

162. R . Potassii iodidi, 

Potassii bromidi, aa gr. x. 

Tincturae iodinii. f. ^ss. 

Aquam destill., ad f.^ij. M. 

He then either punctures through the speculum, leaving the 
uterus free if the os and cervix be very large and low down, or 
fixes it with Sims' tenaculum, using a duck-bill speculum. He 
generally makes from three to five punctures, according to the 
amount of hyperplastic matter to be absorbed. A cotton pledget 
well soaked in glycerine is placed against the part, and rest 
enforced for at least twelve hours. Seldom more than three 



CERVICITIS. 161 

operations are required ; and he has never found any disturbance 
of moment set up, either generally or locally, by the procedure ; 
on the contrary, a number of cases turn out successfully when 
other methods have proved unavailing. 

Internally he uses the bromide of potassium in large doses, 
both for the purpose of quieting excitement, and secondly of 
obtaining some of the benefits described by* Prof. Binz, of Bonn, 
who speaks of the potash salts as being positively specific in sub- 
involution ; and he believes he has many times seen advantages 
derived from a continuous use of this salt, quite equal to those 
described by Dr. R. Williams, who attributed such wonderful 
powers to its action in splenic hypertrophy. 

The above treatment can usually advantageously be joined to 
dilatation of the os by means of a sponge- tent, after the first 
effect of the injections has passed off. 

Richardson's Styptic Colloid. According to Dr. R. E. Beach, 
of Illinois, (Illinois Medical Recorder, August, 1878,) in granular 
conditions of the os, Richardson's styptic colloid painted over 
the os seems to produce good results. " It appears to act as a 
direct alterative, and by forming a protective crust over the sur- 
face, constitutes for it a shield against friction and uterine 
discharges, and by its constringing effects diminishes local con- 
gestion." (For the preparation of the styptic colloid, see 
Napheys' Surgical Therapeutics, 7th ed.) 

DR. HALTON, OF DUBLIN. 

In the Dublin Journal of Medical Science, June, 1876, Dr. 
Halton gives a number of cases, explaining his plan of treat- 
ment, which consisted in producing local congestion by local 
means and touching the excoriated surface with the strong nitric 
a,cid. This was always carried into the cervix when that appeared 
diseased, and the acid brought in contact with the whole surface 

11 



162 DISEASES OF THE UTERUS AND ITS ANNEXES. 

of the canal, and even to the fundus if necessary.* It never 
gave rise to the slightest symptom of danger or distress, and in 
the vast majority of instances was altogether nnfelt. When pain 
did occur, its amount was so trifling as to attract little notice 
from either the patient or physician. Astringent injections were 
found to be of little use, and whether this was from the patient's 
awkwardness in managing them or not, they have been latterly 
dispensed with by hini, and their place supplied by the tannin, 
pessary, or bougie placed in contact with the os or introduced 
into the canal. The skin of the abdomen has been leeched or 
blistered, as seemed most suitable, over the tender spot in the 
region of the ovary, with very marked benefit. When much 
Ieucorrhcea was present, small blisters to the sacrum were found 
serviceable, while ergot and Indian hemp were useful internally, 
particularly when hemorrhage was present; but, .undoubtedly, 
the most generally effective drugs were strychnine, in small doses, 
in combination with dilute nitric acid. The following is the 
formula used : 

163. R. 



Liquor of strychnine, 




f. Z iss. 


Dilute nitric acid, 




f-3ij. 


Tincture of gentian, 




i.% ss. 


Hoffman's solution, 




f-kiij- 


Water, 


q. 


s. % viij. 



M. 

The dose is one tablespoonfnl thrice daily, before meals. If pyrosis is 
present, a drachm and a half of sedative liquor of opium added to the above 
for a week or two, taking care to regulate the bowels Avith suitable aperients, 
will be found serviceable. 



MECHANICAL TKEATMENT. 
T. GAILLARD THOMAS, M. D., NEW YORK. 

When eversion of the cervical mucous membrane is the result 
of injury, as in parturition, an operation is necessary. The edges 

* It is by no means necessary in all cases to dilate the os before touching 
the interior of the uterus with nitric acid. In many cases where this becomes 
necessary, the canal of the cervix is sufficiently patulous to admit the stillette 
covered with cotton- wool soaked in this agent. 



CERVICITIS. 163 

of the fissure must be pared and approximated with deep sutures 
of silver wire. 

A. J. C. SKENE, M. D., XEW YORK.* 

Some preparatory treatment is generally required, before the 
operation can be performed. The cervix is usually found gaping, 
enlarged, eroded from pressure on the pelvic floor, and often in 
a state of cystic degeneration. In a bilateral laceration extend- 
ing nearly, or quite, to the vaginal junction, the eversion of the 
parts is often so great as to require the removal of large portions 
of their surfaces before bringing them into apposition, or the 
tension on the sutures will be so strong as to cause them to cut 
into the tissues and prevent perfect union. 

In these cases, about ten days before the final operation, bring 
the parts together, without any freshening of their surfaces, and 
confine them by means of a small piece of sheet lead on either 
side of the cervix, held in position by a silver suture passed con- 
tinuously through both ends of the leads. Then tampon the 
vagina carefully with marine lint, which can be retained in sitit, 
for two or three days without becoming offensive, thereby pro- 
tecting the surrounding parts from the chafing of the clamp. 
At the end of a week, remove the clamp. Three days later, 
operate. 

The use of the marine lint tampon, above referred to, is, even 
without the clamp, of service in reducing the abnormal condition 
of the lacerated cervix. 

He prefers the ordinary silk suture, as it cuts the tissue much 
less than silver wire. This is easily tied by using Carroll's 
knot ties, or by passing a loop of the Thomas curette, and making 
traction laterally with that, holding the other thread firmly in 
the fingers. For after-treatment the less they are interfered 
with, the better. Remove the tampon in forty-eight hours, and 
do not use the vaginal injection unless absolutely requisite. 

^Proceedings of Kings County Medical Society, June, 1878. 



164 DISEASES OF THE UTERUS AND ITS ANNEXES. 
TENTS FOE DILATING THE CEKYIX. 

The use of tents of any kind is not without danger. Serious 
maladies and death have at various times resulted from their 
insertion. Dr. T. Gaillard Thomas gives the following rules 
with regard to their employment : 

Rule 1. In the introduction of a tent,- no force whatever should 
be employed. Should that first essayed not pass the os internum 
easily, it should be withdrawn and either bent so as to follow 
more accurately the course of the cervical canal, as ascertained by 
the probe, or exchanged for a smaller tent. 

Rule 2. A tent should never, under any circumstances, be intro- 
duced at the physician's office, and the patient allowed to go home 
with it in utero. Such practice is hazardous in the extreme. 
Even when introduced at the patient's home, she should at once 
be confined to the bed. 

Rule 3. The practitioner should always investigate as to the 
previous existence of chronic pelvic peritonitis, one of the most 
common of the diseases of women. Should it have existed, tents 
should be carefully avoided. 

Rule 4. A tent should never be allowed to remain in the uterus 
more than twenty-four hours ; and, if it be compatible with the 
accomplishment of the desired result, it should be removed in 
twelve hours. 

Rule 5. After the removal of a tent, the vagina should be 
washed out with an antiseptic fluid, and if any pain, chilling or 
discomfort, follow the removal, opium should be freely adminis- 
tered and perfect rest enjoined. 

Rule 6. After the removal of the tent, the patient should be 
kept in bed at least twenty-four hours, and never allowed to 
travel before the expiration of four or five days. 

Dr. Tilt lays stress on the importance of examining the 
patient with a speculum in' full daylight, to be sure nothing is 
amiss with her pelvic organs. A tent should only be introduced 
every third or fourth day, and at some days removed from the 
menstrual epoch. If much irritation is produced, the dilatation 



CERVICITIS. 165 

should be suspended. Vaginal injections should be used with 
great care at this time, as severe uterine colic may result from 
the fluid entering the dilated os. 

Dr. Beverly Cole, of San Francisco, states that most of 
the sponge tents sold are carelessly prepared. Therefore he 
makes his own tents out of fine cup sponge, such as surgeons 
use. The sponge is dipped in melted wax, and then subjected 
to a very great pressure (which could best be secured by a letter- 
press) which forces all the superfluous wax out of the sponge, 
and flattens it out to a thin cake. It is necessary, in selecting 
the sponge employed, that it should be entirely free from all 
coral or other mineral impurities. After being pressed out in 
this way, the sponge can then be cut with the knife or scissors 
into any shape desired, care being taken to cut it in the direction 
of its long axis. In many instances it is very necessary to begin 
with a tent not larger than a knitting-needle. Before using, it 
should be provided with a thread by which it can be removed. 

Dr. James P. White (Trans, of the Amer. Gyn. Soc, 1880,) 
insists very strenuously that the twine or wire used to withdraw 
a sponge tent should run quite to the small or internal end, and 
should be securely fastened thereto ; otherwise the tent is liable 
to part in the middle, and the inner portion slip into the uterine 
cavity. 

Professor B. S. Schultze, of Jena, teaches that all forcible 
dilatation is dangerous on account of the open wounds it makes 
in the mucous membrane, from which septic poisoning may oc- 
cur. He insists on the following precautions in dilating the 
uterus : The patient should be in Sims' or the knee-and-elbow 
position. A catheter being passed into the vagina, it should be 
washed with five per cent, solution of carbolic. The dilating 
material should be disinfected before introduction. Tupelo or 
laminaria is the best material. Sponge tents should not be used, 
because in spite of every precaution the secretion becomes putrid, 
and its meshes penetrate and wound the mucous membrane, thus 
giving rise to two favorable conditions for infection. If sponge 
tents be used they should be made of disinfected sponges and 



166 DISEASES OF THE UTERUS AXD ITS AXXEXES. 

saturated with carbolic wax. Schultze prefers the larninaria, 
because by clipping one into boiling water he disinfects it, and 
at the same time makes it capable of being bent to suit the angle 
of the uterus ; it is then greased with carbolic oil and introduced. 
A carbolized glycerine tampon holds the larninaria in place ; 
after six to eight hours the tent is removed ; the uterine 
cavity is disinfected; then several laminarise or tupelo are 
introduced, as before. The finger and every instrument 
which is passed into the uterus must be clean and well carbol- 
ized. The results of infection can be from the smallest para- 
metritis to peritonitis, or death from septicemia or pyaemia. The 
prevention of the presence of putrid matter and the avoidance 
of injury to the mucous membrane, either by introducing the 
lamiuarise or shortly before, are the only ways we have to re- 
duce the danger to a minimum. If we wound the mucous 
membrane with the sound or larninaria as shown by a slight 
flow of blood, it is better to wait twenty -four hours before we 
dilate. Should infection take place, the treatment is the same 
as in puerperium. Schultze has dilated for diagnosis and op- 
eration one thousand cases with the above precautions ; has no 
death and but five cases of parametritis, none of which were 
severe. 

Dr. B. S. Schultze, of Jena, (Centralblatt fur Gyncekologie, 
Xov. 7th, 1878,) uses sea-tangle tents with strict antiseptic pre- 
cautions, and having succeeded without an accident in several hun- 
dred cases, believes that if his method is followed the usual con- 
tra-indications to dilatation of the cervix may be dispensed with. 
One principle of his procedure is the assumption that for safe 
dilatation the tangle tent must never come in contact with a raw 
wound surface. But, besides this, he takes the strictest antisep- 
tic precautions that the conditions of the operation allow of. 
He first employs flexible copper sounds, of varying thickness, 
by which he ascertains the exact size and curvature of the cervi- 
cal cavity. Having settled these points, a tangle tent, corres- 
ponding in thickness with the sound, which just passes the cer- 
vical cavity, is immersed for one or two minutes in boiling 
water, and being thus rendered flexible, the same curvature is 



CERVICITIS. 167 

given to it as that of the sound, which has been previously 
adapted to the cavity of the uterus. On cooling, the tent re- 
tains the curvature thus communicated to it, and after steeping 
it in a 3 / 100 solution of carbolic acid, it is introduced through a 
speculum, the cervix being meanwhile held down by an assist- 
ant with a hook or vulsellum. If a drop of blood is seen com- 
ing from the cervix during any of these processes, the operation 
is to be postponed for at least twenty-four hours. The patient . 
is to be kept strictly at rest during the whole time that the tent 
is dilating, and the strictest care is to be taken in the removal 
of the distended tent that no injury is caused to the cervix. 
The vagina and cervical canal ought to be then carefully washed 
out with a 3/200 solution of carbolic acid. 

It is remarked by Dr. W. Goodell, that the danger of insert- 
ing tents increases with each introduction. Hence the import- 
ance of dilating the canal with one or at most two introductions. 
When sponge or laminaria is used, the cervix should be irrigated 
every few hours with a strong solution of table salt or of 
chlorate of potassa. 

KESUME OF KEMEDIES. 

AGENTS APPLIED TO THE OS. 

Acetum. For removing sanguinolent or albuminous discharges 
in cervicitis, Dr. James P. White (Trans, of the 
Amer. Gyn. $oc.,1880, recommends common vinegar. 
It coagulates the albuminous secretion, is a good astrin- 
gent, and does not discolor the surface to which it is 
applied. Dossils of cotton saturated with vinegar will 
be found exceedingly convenient. 

Acidum Acetum, in crystals, is said to be but slightly painful 
and very efficient. 

Acidum Bichloraceticum has been recommended by Schmidt and 
Urner. It is obtained by the action of chlorine on 
hydrated acetic acid under the influence of the solar 
rays. 

Acidum Carbolicum, in crystals, is an efficient agent, and as it is 



168 DISEASES OF THE UTERUS AND ITS ANNEXES. 

also a local anaesthetic, the pain is less prolonged than 
with the mineral acid. Galabin considers it the most 
widely useful of all applications for the cervical canal. 
The vagina must be protected and well washed out 
after the application. It may be diluted with glycer- 
ine, 1 to 5 parts. 

Acidum Chromicum is preferred by Dr. Kceberle for the rea- 
sons given. (P. 158.) It is also a favorite with some 
American practitioners. Dr. Atthill says it is more 
irritating than nitric acid. 

Acidum Nitricum is preferred by A. Courty and others to any 
other caustic. Dr. Atthill has especially advocated 
it in Great Britain. 

Acidum Pyroligneum was used largely by Scanzoni and the 
Vienna school. 

Alumen, in powder, or ointment, or strong solution, or as burnt 
alum, has been occasionally employed. 

Antimonii Chloridum is an energetic caustic, but of uncertain 
action. 

Argenti Nitras has long been the most popular of all caustic ap- 
plications to the os uteri. Dr. Tilt observes : " I 
have no hesitation in saying it is the most valuable of 
all the agents that enable us to cure inflammatory af- 
fections of the reproductive mucous membrane." His 
usual solution is gr. xl. to aqua? f. ij. He applies it 
every four or five days when the os is red and sensi- 
tive, as well as when ulceration is present. 

Bismuthi Subnitras. Dr. A. Courty (Maladies de V Uterus, 
1 866,) considers this substance, insufflated upon the part, 
one of the most powerful modifiers of ulcerations of 
the os. It has also been very strongly recommended, 
made into a thick cream with glycerine, applied to ul- 
cerations of the os. It may be conveniently intro- 
duced through a tube, and retained in place by a 
pledget of cotton. 

Creosotum was formerly used, but carbolic acid has taken its 
place. 

Cupri Sulphas is a favorite agent with the Swedish physicians. 
They claim it is curative, and not followed by trouble- 
some sequelae. 

Ferri Chloridi Tinctura. For hemorrhage depending on a gran- 



CERVICITIS. 169 

ular condition of the cervix, this is a valuable agent. 
It is best applied on a small roll of cotton saturated 
with it, another and larger roll wet with glycerine being 
placed outside it. (Atthill.) They should not be left 
over a few hours, or sloughing may ensue. Aran 
applied to ulcers of the os the following glutinous com- 
pound : 

164. R . Tinct. ferri chloridi ether., 

Collodion, aa equal parts. M. 

Ferri Subsulphas has been largely employed as a styptic, espe- 
cially in the form of MonselPs solution. 

Hydrargyri Nitras. The acid nitrate of mercury is well spoken 
of by Tilt and other practitioners. It must be ap- 
plied with considerable care, so as to avoid injuring 
other parts, and a solution of bicarbonate of soda should 
be at hand to neutralize it. On the other hand, Atthill 
never employs it, and A. Courty [Maladies de 
V Uterus, 1866,) formally condemns it as difficult of 
management and liable to be followed by severe mer- 
curial poisoning. 

Iodinium. In ulcers of the os, iodine is not so effective as nitrate 
of silver (Tilt), but when the latter disagrees, tincture 
of iodine is the best application. To the simple 
tincture Dr. Goodell prefers the saturated ethereal 
tincture. 

Iodoformum is a soothing and healing application,, principally 
objectionable from its odor and the unpleasant taste it 
imparts. The odor may be largely disguised by com- 
bining with it double the quantity of balsam of 
Peru. 

Pix Liquida has been employed by Bell. 

Potassa Fusa. This is principally used in the form of potassa 
fusa cum calee, which is of two strengths, known 
respectively as, 
Filhos' caustic : 

165. R . Potassa? fusse, 1 part. 

Calcis, 2 parts. 

Melt together. 



170 DISEASES OF THE UTERUS AND ITS ANNEXES. 

Bennett's caustic: 

166. R. Potassse fusae, 2 parts. 

Calcis, 1 part. 

Melt together. 

Dr. Tilt says that in obstinate cases of unhealthy 
condition of the lining membrane of the cervix, in 
highly irritable ulceration of the cervix with soft 
hypertrophy, in pseudo-membranous ulceration of the 
neck, and to establish an issue on the healthy mucous 
membrane covering a hard hypertrophied cervix, these 
preparations are exceedingly useful. Dr. Atthile 
finds the caustic potash eminently useful in those cases 
where the os uteri is in a state of granular erosion. 

Potassii Iodidum acts as a moderate caustic in certain cases. 
(See page 148.) 

Pyroligneum Acidum. Crude pyroligueous acid has been recom- 
mended as a local application to erosious of the os by 
SoANzoNi, Veit and Schroder. 

Salicylicum Acidum. The following combination is praised by 
Dr. Henrot, (Union Med., 1880): 

167. R. 



Acidi salicvlici, 




Pulveris camphorse, 
Mix, and add, 


aa % iiss. 


Alcoholis, 
Unguenti petrolei, 


gttx. 
3 iiss.-v. 



M. 

This is stimulating and slightly caustic, and acts well 
in durated ulcerations of the os. 

Tannicum Acidum is frequently employed as a stimulating appli- 
cation. It may be made into a crayon by moistening 
with glycerine, rolling out, and drying. 

Zinci Chloridum. This agent is a very painful one. 

Zinci Sulphas. In the more chronic stages of cervical endome- 
tritis, solid points of fused sulphate of zinc have been 
introduced by Dr. Braxton Hicks, and are often 
useful, but are liable to cause considerable pain and 
irritation when any active hyperemia is present. 

uterine tents. 

Atthea. The root of the marshmallow has been employed as a 
tent. 



CERVICITIS. 171 

Cloth. Tents made of cloth were introduced in 1871, by Dr. V. 
H Taliaferro, of Georgia, (Jour. Gyn. Soc, Boston, 
vol. T 7 .,) and have been advantageously employed. 

Corn-stalk Pith. In the Transactions of the Medical Association 
of Georgia, 1878, Dr. VV. T. Goldsmith urges many 
reasons for the use of this substance for tents. Take a 
joint of dried corn-stalk; strip it of its cuticle, and 
compress the pith, slowly and firmly, between the 
thumb and index-finger. By continued pressure, it is 
reduced to four or five times less than its original sifce. 
It has a dilating power equal to sea-tangle or sponge. 
The corn-stalk tent is of easy introduction. Its rigidity 
overcomes any slight resistance. Dr. Goldsmith has 
used this tent for the last seven years. He has not 
had a single accident from its use, although he has 
introduced the tents many hundreds of times. The 
advantages of this corn-stalk tent are that it dilates 
s effectually, but not too rapidly. It is smooth, soft, 
and can be removed without force. It produces no 
lacerations, abrasions, or irritation of the mucous mem- 
brane. It can be medicated with any substance as 
easily as the sponge or cloth tent. It is of vegetable 
origin, and hence does not become putrid and poison- 
ous to the patient, and it may be retained, non -com- 
pressed, for days without injurious results, if no pain 
occurs. 

Gentian Root. French physicians have used this occasionally. 
It does well as a dilating agent. 

Ivory, which has been softened by exposure to acids, is recom- 
mended by some. In twenty-four hours it swells to 
double its first size. 

Laminaria or Sea-Tangle. This aquatic plant swells, when 
moistened, to three times its size when dry. It has the 
advantage over sponge that it contains no animal 
matter, and emits no fcetor. When perforated from 
end to end as recommended by Dr. Greenhalgh, 
such tents dilate rapidly and also allow the fluids of 
the uterine cavity to escape. They cause, however, 
much severer pain than sponge, and run a danger of 
tearing a resisting os. Mr. Tait disapproves of them 
for these reasons. 

Slippery Elm Bark. This substance is praised by Dr. William 



172 DISEASES OF THE UTERUS AND ITS ANNEXES. 

Goodell as a material for tents. Though of less 
expansive power than larninaria or sponge, it may be left 
in longer, as it softens down, and becomes dissolved by 
the discharges. It is of especial value in cases requir- 
ing no very great dilatation, but a prolonged treatment, 
such as in flexions. 

Sponge. This is the substance preferred by many for tents. Its 
expansive power is considerable and it is easily adjusted 
to the size and shape of the neck. But it produces a 
foetor which is but partially overcome by treatment 
with carbolic acid and irrigation of the vagina. Tait 
prefers sponge tents, impregnated with oil of cloves, 
but adds that even with these there is some risk of 
infection, and to secure entire immunity recommends 
that the tent be enclosed within an elastic capsule. 

Tupelo. The root of the tupelo tree, Nyssa multi flora, has been 
advocated, by Dr. G. E. Sussdorf, of New York city. 
It is light, smooth, and its power of absorption is said 
to be greater than that of sea-tangle. 

OTHER MEASURES. 

Galvanism. In ulcerated os with leucorrhoea, Dr. O. E. Her- 
rick, of Greenville, Michigan, writes to the New . York 
Medical Record, 1879, extolling this line of treat- 
ment. He introduces a pessary made of a ring covered 
with rubber and supported by a Y-shaped support of 
twisted silver wire, held up by a perineal band. Out- 
side, and held up by the waist-band, is a small plate of 
zinc, enclosed in a chamois-skin bag with a sponge 
moistened with vinegar. The zinc plate is united to 
the silver wire of the pessary by a copper wire, thus 
making a complete galvanic battery. In one patient, 
in thirty-six hours after the galvanic attachment was 
made, he found healthy granulations instead of .the 
unhealthy ulcer; and the leucorrhoea had stopped 
almost entirely, which had not taken place for a year 
before. In one week, there was neither ulceration nor 
leucorrhoea ; he then removed the copper wire and zinc, 
but left the uterine supporter a week longer. The 
patient was discharged cured, and remained so after 
the removal of the apparatus. 



DISPLACEMENTS. 173 

Local Blood-letting. Prof. J. Y. Simpson says frequently 
where there is engorgement or hypertrophy, the ab- 
stract! rn of two or more ounces of blood greatly 
relieves the stress from which the patient is suffering, 
and aids in the beneficial results from other remedies. 
This may be effected by leeches applied to the cervix 
through the speculum, or by scarifying around the os 
with a tenotomy knife with a long stem. It is well to 
make the patient sit over a dish of hut water to favor 
the flow, and then apply a warm vaginal douche, taking 
care that the patient is not wetted and chilled during 
the process. 



DISPLACEMENTS 



Displacements of the uterus would seldom require mechanical 
treatment if the congestion and other affections were properly 
treated. It is bad practice to employ mechanical measures prior 
to the cure of inflammatory lesions. This, by diminishing 
enlargement, will likewise relieve displacement. The stem 
pessary will not be borne, when the cervical mucous membrane 
is inflamed. When the displacement is congenital or of long 
standing, the cure of the inflammation does not correct it, but 
by a tonic treatment, with opium suppositories at night, astrin- 
gent injections, and electricity, many are enabled to perform 
their household duties. Always make light of displacements to 
the patient, as otherwise fright interferes with the cure. 

Retroversion and antervesion depending greatly upon relaxa- 
tion of the vagina, astringent injections prove of value, as strong 
solutions of alum, sulphate of zinc, or tannin. Aid is obtained 
by suppositories containing alum, iron alum, tannin, or matico. 
A good plan is to enclose in cotton-wool a small lump of alum, 
the size of a hazel-nut, tie round it a string long enough to hang 



174 DISEASES OF THE UTERUS AND ITS ANNEXES. 

out of the vagina, then place the alum ball as high as possible in 
the vagina. The wool imbibes the fluids, the alum gradually dis- 
solves and acts powerfully on the vaginal walls. Remove the 
wool next day and irrigate the vagina freely to remove the coagu- 
lated mucus, prior to a second application. Cold vaginal douches 
are often useful, applied twice a day, for fifteen or twenty 
minutes. Douching the loins, while the patient is perspiring 
from a vapor bath, often relieves the pains of displacements. 

Prolonged repose is hurtful, though rest for a few hours daily 
in the recumbent posture will diminish pain and congestion. 
Consider the periods of menstruation as seasons of disease, and 
enforce complete rest, with the use of hip-baths and large abdo- 
minal poultices. Parturition generally greatly modifies and 
even cures uterine displacements. They are then mechanically 
rectified, and the active nutrition furnishes sounder tissues. 
Hence, after parturition, in such cases keep the patient on her 
back longer than usual, and employ twice daily after the red 
lochia have ceased, astringent injections, and continue them for 
months. 

When adequate improvement does not follow constitutional 
treatment, mechanical means may be employed. The womb 
may be placed at rest by a hypogastric bandage with a vertebral 
support. It takes off the pressure of the intestines. Prolapsus 
and procidentia may be greatly relieved by the styptics as above. 

In case of complete prolapse, when the womb cannot be re- 
placed, its volume may be diminished by scarifications and lead 
lotions, or, when necessary, by strapping it with strips of adhe- 
sive plaster until its size is reduced. Then, with the patient in 
the genu-pectoral position, the surgeon may force the womb back 
into the pelvis. 

Globular pessaries of boxwood or vulcanized rubber are often 
useful, and may gradually be reduced in size, till they can be 
omitted. The air pessary will often give great relief, even 
though it does not cure the displacement. 

All pessaries should be occasionally removed and cleansed. 

A pessary made of rubber- covered watch-spring is easy of in- 



DISPLACEMENTS. 175 

troduction, and tends to counteract' the relaxation of the vaginal 
walls. A heavy prolapsed womb is well supported by Coxeter's 
gutta-percha pessary, which resembles a funnel, the mouth cov- 
ered with thin vulcanized rubber on which the womb rests. 
This membrane is pierced with holes to permit the secretions to 
drain off freely. Another by Coxeter has a spring which dis- 
tends a thin rubber cup which supports the womb ; the lower 
end is fixed in the perineal band, so that the patient can remove 
or draw it aside. Bourjeaud's mushroom pessary is made of 
vulcanized rubber, and may be inflated by a tube after it is 
placed. When distended, it is well calculated to support the 
neck of the womb in the depression in its upper part. It is se- 
cured by elastic bands fastened to an abdominal belt. It has 
two advantages — its size may be regulated, and it diminishes 
vaginal irritation. 

In complete prolapsus, the tow-pessary may be employed. 
The vagina, after replacement, is packed with carded oakum, 
called " antiseptic marine lint," or with chloralum cotton-wool. 
The vagina is allowed a limited power of contraction, the pres- 
sure does not cause pain, and the pessary is not readily displaced, 
nor does it interfere with the functions of the surrounding or- 
gans. The plug should be replaced weekly, less being required 
each time. This is highly praised by Dr. Copeman, of Nor- 
wich, and Mr. Morgan, of Litchfield. 

Various plans have been proposed to narrow the vagina, and 
thus cause the womb to be retained. 

Dr. Marion Sims cuts off slips of mucous membrane at appro- 
priate distances, and brings the cut surfaces together by silver 
sutures. 

When old adhesions prevent the reposition of the womb, 
Edwards, of Denbigh, and others propose its removal. In 
three-fourths of these cases, the operation has been followed by 
recovery. 

For uterine flexions, Dr. Goodell, of Philadelphia, intro- 
duces into the cervix a powerful dilator and forcibly dilates it, 



176 DISEASES OF THE UTERUS AND ITS ANNEXES. 

so as to crack the circular fibres. This is done under ether, and 
is claimed to be very successful. 

LOMBE ATTHILL, M. D., DUBLIN, 

In retroflexion, believes that where a pessary can be borne, its 
action will aid the cure. He prefers Hodge's lever pessary with 
transverse bars ; or Dr. Greenhalgh's spring pessary, which is 
made of copper wire bent like the Hodge pessary, cased in rub- 
ber tubing ; but the wire is wanting at the lower or wide end, 
the tubing alone crossing there. A double advantage is that the 
tubing here adapts itself to the parts and does not irritate the 
neck of the bladder, and also it permits the sides to close during 
introduction. Great care is requisite in adjusting the pessary as 
to its size. When too large it causes pain ; when too small it 
slips out. Stem pessaries are especially useful in dysmenorrhea 
with retroflexion. The best is Greenhalgh's flexible pessary ; 
the stem is of rubber tubing, admitting an ordinary sound, which 
must be passed into it when being introduced. Near the upper 
extremity is a bulb with four slits in it, through which the 
secretions escape; the lower extremity terminates in a shield. 

Stem pessaries should never be left in longer than a month, 
and should be avoided if possible. 

Bear in mind that cases are often met with which seem to cause 
no distress, and should not be interfered with. 

Retroversion is rare, and is generally connected with preg- 
nancy, and usually occurs at the close of the third month, caus- 
ing retention of urine ; on emptying the bladder a globular body 
will be found occupying the hollow of the sacrum, while the os 
uteri is high up behind the pubes, and the fundus will be found 
absent from its proper place. 

Two indications are to keep the bladder empty, and to restore 
the uterus to its normal position. In these cases always use a 
long gum catheter. If the attempt to restore the womb cause 
great pain, it is better to wait a few hours, and calm excitement 



DISPLACEMENTS. 177 

by a suppository of morphia. Place the patient on her side, or 
better in the geim-pectoral position, and with two fingers in the 
vagina press the fundus up laterally, so as to avoid the sacral 
promontory. In case this fails, introduce a Barnes rubber bag 
into the rectum, distend it with water, and at the same time 
make pressure with the fingers in the vagina. Should all such 
efforts fail, abortion must be induced or death will result. After 
the reduction has been accomplished, the patient must be kept 
at rest, the bladder carefully emptied at proper intervals, and if 
the uterus again tends to fall, this must be prevented by keeping 
her in the recumbent position. 

Anteflexion is very common, and is generally the result of 
congestion, etc. Puncturing the cervix will alone often give 
marked relief. The fundus can be raised by means of the 
sound, and supported by the stem pessary. 

Prolapse of the uterus must not be confounded with cystocele, 
with which it is often complicated. Absolute rest in the recum- 
bent posture, even with the lower part of the couch elevated, is 
very useful, but after all, it is only palliative. Some support is 
required. The best is Hodge's pessary, a wide one with trans- 
verse bars. These bars prevent the anterior walls from prolaps- 
ing. Dr. Godson, of St. Bartholomew's, has invented a pessary 
with vulcanite wings, which are movable. The wings are closed 
on introduction, and then expanded by bringing the metal feet 
together, where they are locked. This should be removed and 
replaced night and morning. In cases with large protrusion and 
greatly relaxed perinseum, operative means must be employed to 
narrow the vagina. Sims removes a portion of the mucous 
membrane in the shape of a V from the anterior wall, the apex 
near the bladder, and the arms extending either side of the cer- 
vix. This opening is closed by means of wire sutures. In cer- 
tain cases, it may be useful to repeat this procedure on the pos- 
terior wall. 

Where the cervix is very long, relief may be obtained by its 
amputation by means of the ecraseur. 

12 



178 DISEASES OF THE UTERUS AND ITS ANNEXES. 

Inversion of the uterus is rare, and generally occurs soon after 
delivery. In all cases, its reduction should be attempted by the 
taxis, under chloroform. Should this fail, continuous pressure 
exerted by a rubber bag in the vagina, inflated, and retained by 
a bandage will reduce it. 

All failing, it should be amputated by means of the ecraseur. 



THOS. ADDIS EMMET, M. D., NEW- YORK. 

In all versions, correct the displacement by mechanical means, 
and relieve the local cause of disease. The latter should consist 
in- the frequent and continued use of hot water injections, etc. 
This gives tone to the blood-vessels. 

A retroverted uterus may be lifted into place by the use of the 
index-finger, and is the most reliable means we can employ. It 
is attended with the least risk, and we are able to appreciate at 
once, in case of adhesions, the point and extent of resistance. 
The patient is to be placed on her back, the knees flexed, the 
hips drawn down to the edge of the couch. The index-finger is 
introduced into the vagina, and the point of a tenaculum hooked 
into the posterior lip within the os. By this the organ is drawn 
toward the outlet so that the fundus may clear the promontory. 
This manipulation must be done with care, and if great pain is 
caused, it must be suspended. This manoeuvre causes a still 
greater retroversion; to correct this, the perinaeum is to be pressed 
firmly back, that the finger in the vagina may be passed up far 
behind the uterus so as to lift that organ. The fundus thus ele- 
vated, the cervix is to be suddenly carried in an arc of a circle, 
downward and backward by means of the tenaculum. The ver- 
sion completed, the fundus can by the finger be pressed up 
against the uteri-sacral ligaments. These gape as the tension is 
relaxed by carrying the cervix backward, and the fundus slips 
between them. The finger is to be quickly passed from the pos- 
terior cul-de-sac against the anterior lip, the tenaculum withdrawn 



DISPLACEMENTS. 179 

and the womb thrown forward by passing the finger repeatedly 
down the anterior face of the uterus, so as to press the cervix 
downward and backward into the hollow of the sacrum. This 
operation, especially when it has caused much pain, should be 
followed by a hot water injection, and a glycerine dressing in the 
vagina, and several hours' rest. 

On the subject of pessaries this author says : In adjusting a 
pessary great regard should be paid to the shape and size of the 
vagina, as scarcely two women could be benefited by the same 
instrument. The object is to restore the uterus to its proper 
place, and thus completely establish the circulation. Raise the 
uterus gently on the tip of the finger, until the patient expresses 
a feeling of relief from all feeling of fullness and bearing down. 
This is to be the guide. The pessary is then to be fitted so as to 
maintain the womb at this point. When the instrument fits 
properly, and has corrected the malposition, the patient should 
be unconscious of its presence. The largest number of cases 
will be relieved by some modification of Hodge's closed lever 
pessary. All outside appliances should except in extreme cases, 
be avoided. The instrument should, remain unchanged for 
months, while the parts are recovering their tone. Block tin 
rings made of an alloy of tin and lead in such proportions as to 
be easily moulded, and yet unyielding enough for the pessary to 
keep its shape, make the best. The support for the instrument 
is to be taken from the bottom of the posterior cul-de-sac. Hard 
rubber may also be used for the same purpose. To receive the 
full benefit, the vaginal outlet should not be too large, and the 
posterior cul-de-sac should be of a natural depth. "' The ful- 
crum of this double lever rests on the bottom of the cul-de-sac, 
and in front against the posterior wall of the vagina. It should 
be curved at one extremity with reference to the shape of the 
cul-de-sac and posterior wall, and bent at the other end in the 
opposite direction with a lesser curve, so that it will be balanced, 
as it were, in the vagina." When the patient stands, the weight 
of the uterus will be thrown on the short lever forming the 
long curve in the posterior cul-de-sac. This causes the other 



180 DISEASES OF THE UTERUS AND ITS ANNEXES. 

end to rise and rest against the anterior wall of the vagina near 
the neck of the bladder. In the horizontal position, the weight 
is removed, and the long lever rests in the axis of the vagina. 
By thus adjusting itself, it cannot press so as to cut into the 
vaginal tissues. 

The pubis should be avoided as the chief point of support, if 
possible; but this must be, when the anterior wall of the vagina 
is shortened by reason of an old retroversion, and where prolapse 
of the posterior wall occurs from perineal laceration. An opera- 
tion here becomes necessary. But for a temporary pessary, the 
only point of support is behind the symphysis. Under such cir- 
cumstances, the instrument must be wider below, and with the 
greater curve at this end, that downward pressure may crowd the 
other extremity up behind the pubes. Here a depression must 
be made to receive the neck of the bladder. The general laws 
for all pessaries are, that the instrument shall be small enough 
to admit the finger between it and the vaginal wall at any point 
while the patient is on her back ; it must be large enough to 
support the uterus, and yet allow the vagina to regain its normal 
size. To get the lengtii for a pessary, the patient being on her 
back, pass a whalebone stick or any blunt instrument along the 
index finger into the posterior cul-de-sac, and measure from be- 
hind the pubes. Next, to get the proper curve. In retrover- 
sion, a longer curve is needed than when there is only a pro- 
lapse. Here the upper part of the vagina is more dilated than 
below, to which the instrument must conform, but not with so 
abrupt a curve as to press directly against the junction of the 
vagina, but beyond it, otherwise the circulation in the neck and 
womb is hindered, and engorgement and erosion follow. 

Where there is thickening of the posterior wall and retrover- 
sion, the curve must be such that it will pass far beyond into the 
cul-de-sac. This extremity must be rounded gradually, and not 
be made too narrow for its length. In cases where the thick- 
ened edges of the ligaments are very sensitive, this must be 
removed by hot water injections, and the free application of 
iodine to the cul-de-sac every third or fourth day, and to take 



DISPLACEMENTS. 181 

off the pressure, the recumbent position should be maintained. 
To allow of exercise, temporary support may be given by a cot- 
ton pessary, shaped like a large mushroom, and placed in front 
of the cervix. This is made by pressing a square pledget of 
damp cotton between the hands, and folding the corners towards 
the centre until a ball is formed of the proper size ; then holding 
the extremities between the fingers, a stem is made by wrapping 
cord between the ends and the ball portion. This saturated with 
glycerine, will readily support a prolapse. 

When the cul-de-sac is absent or very small, a straight or flat 
pessary is used, fitted to receive support behind the symphysis, 
and put the vagina on the stretch so as to carry the uterine neck 
so far back as to make an anteversion. This must be watched 
lest it cut into the tissues. The shorter the vagina, the straighter 
must be the instrument, lest it rotate and remain across the axis 
of the canal. It must be wider in the middle than a curved one, 
in proportion to its length. 

There is also a hollow rubber disk, which is useful in place of 
the cotton pessary where glycerine is not to be used. It is most 
useful where tenderness prevents the use of the ordinary form. 
To prevent pressure on the urethra or any tender point, a sulcus 
may be made by passing a small elastic band once or twice 
around its thickness. It may be placed in front or behind the 
uterus as occasion may demand. It prevents the sagging of 
the uterus in the pelvis. As rubber causes an offensive dis- 
charge by long retention, it is only temporary and should be re- 
moved at night, or when not needed, as in exercising. 

Sponge must never be used as a pessary. 

In flexures of the uterus, this author says as soon as the true 
condition is appreciated, the intra-uterine stem will be aban- 
doned, as also the practice of dilating with steel swunds or 
sponge tents. The use of either is faulty in theory, without 
permanent benefit, and always dangerous. Where flexure is 
below the vaginal junction, surgical aid may be useful. The 
proper time is shortly after the menstruation, and the incision 
should be made backward. In flexures of the body of the 



182 DISEASES OF THE UTERUS AND ITS ANNEXES. 

womb, hot water injections will give tone to the vessels. Iodine 
should be frequently applied to the canal by the applicator bent 
to a curve corresponding to the flexure. When the uterus is 
enlarged, and the cervix hard, the acetic solution of cantharides 
should be applied to the neck after each period, to produce a 
blister. This relieves the congestion and, acts revulsively and 
also produces uterine contractions. Glycerine on cotton must be 
used daily, and ergot with tonics given internally. It must be 
continued for a long time and not in doses to cause irritation of 
the stomach or marked uterine pains. When absorption of 
tissue has left a permanent deformity, and there is no cellulitis, 
it is well to open the passage in order to prevent dysmenorrhoea. 
The posterior lip is to be divided backward, and a triangular 
portion raised and removed. Though occasionally successful, 
yet it often fails and there is a return to the old condition. 

Where procidentia exists to such a degree that the pessary 
cannot retain it, a surgical procedure becomes necessary. The 
object is to reduce the size of the vagina, which is accomplished 
by taking in a plait. 

In obstinate cases, this author anteverts the uterus with the 
finger as the patient lies on her back, and the neck of the womb is 
crowded into the posterior cul-de-sac by a sponge probang held 
by an assistant. He then seeks a point about half an inch to 
either side of the cervix and a little behind the line of the ante- 
rior lip, which two points can be drawn together in front of the 
uterus by a tenaculum in each hand. The surfaces are denuded 
and- a similar surface in front of the uterus. A needle armed 
with a silk loop is passed beneath each freshened surface and 
they are brought together and held by a silver wire attached to 
the hoop ; the folded surface is denuded below and the joints 
united by sutures. 

THOMAS EDIS, M. D., OF THE MIDDLESEX HOSPITAL, LONDON. 

This writer observes that the genu-pectoral position proves of 
much service in all cases of retroversion and retroflexion, more 



DISPLACEMENTS. 183 

especially when metritis also exists. In a short time patients 
become accustomed to the posture, and will say that they can 
get more relief in one hour by resorting to this method than by 
lying down in the ordinary position for several consecutive hours. 
The, uterus falls forward in the abdomen, pressure posteriorly 
being thus removed ; the distressing pain in the back, frequently 
complained of in these cases, disappears within a short time. 
In many instances, where a Hodge's pessary cannot be tolerated 
under ordinary circumstances, by restoring to this position for a 
quarter of an hour occasionally during the day, the instrument 
can be worn with comfort. The genu-pectoral position, also, 
offers manifest advantages in the replacement of the retroverted 
gravid uterus; also in pressing the uterus up beyond the pelvic 
brim in cases of impacted fibroids. In cases of prolapsus and 
subinvolution, much may be gained by adopting this position. 
In the morning sickness of early pregnancy, and in cases of pro- 
lapse of the ovary, considerable relief may be thus obtained. 

DR. JOHN WILLIAMS, OF LONDON. 

Chronic inversion of the uterus frequently demands surgical in- 
terference for its relief. In some cases, however, success may be 
achieved by the use of the repositor, or by elastic pressure. An 
instance of the successful employment of the latter is described by 
Dr. John Williams, of London. (Obstet. Journal, April, 1879.) 
A cup of vulcanite mounted on a metallic stem, having a peri- 
natal curve was introduced. The cup was applied to the inverted 
fundus, and to the ring at the end of the stem were fastened 
four elastic bands, two of which were carried anteriorly between 
the thighs in front of the abdomen, and fastened by tapes to a 
broad strap of adhesive plaster placed round the waist; the other 
two elastic bands were carried posteriorly and fastened by simi- 
lar means to the adhesive strap in such a mauner as to cause the 
force exerted upon the fundus uteri to act, as far as could be 
judged, in the axis of the brim of the pelvis. There was some 
systemic and local reaction to the use of this apparatus, but after 



184 DISEASES OF THE UTERUS AND ITS ANNEXES. 

the first day no pain was complained of, and in two days the 
uterus reverted to its normal position and the cup was with- 
drawn. 

PROF. MONTROSE A. P ALLEN, M. D., OF NEW YORK. 

In cases where there is so much tenderness of the uterus and 
vagina, that an ordinary pessary cannot be worn, this gynecolo- 
gist is in the habit of daily reducing the version by placing the 
woman in the genu-pectoral position, and lifting the perinseurn 
so that the vagina becomes ballooned and the uterus falls into 
the axis of the inlet, which is kept in position by introducing 
into the anterior and posterior arches of the vagina sufficient 
thymolized clay* to fill the upper third of the canal, the lower 
two-thirds being padded with soft cotton. This makes a perfect 
pessary-support, retaining the uterus, bladder, and rectum in 
normal relationship. Prior to the next visit of the physician, 
the patient removes the cotton, and washes out the thymolized 
clay, when the same process is undergone again. It is remark- 
able how rapidly some patients yield to this process of treat- 
ment. In many instances in pregnant women, it is necessary to 
continue this method of procedure until the uterus rises from 
the excavation, lest abortion ensue in consequence of jamming 
under the sacral promontory in retroversion, or cystitis develops, 
because of the constant hyperemia engendered by superincum- 
bent uterine pressure. 



This writer (Dublin Journal of Medical Science, Feb., 1879,) 
lays down the following : 

Rules for the use of pessaries, the strict observance of which, 
he states, will tend much to the safety and comfort of patients, 

*See under Pruritus of the Vagina for the formula. 



DISPLACEMENTS. 185 

and prove the surest safeguard in preventing all the accidents 
arising from the use of pessaries : 

1.. In no case should a physician use a pessary without telling 
his patient that he has done so. 

2. That inasmuch as a pessary should give rise to no pain or 
uneasiness whatever, after its introduction, the patient should 
immediately come back, in the event of any such symptom oc- 
curring. 

3. She should return to have the instrument examined or re- 
moved, not later than six weeks or two months. 

4. That, in the event of any sensation of heat, pruritus, or 
irritation of the vagina, or the occurrence of any discharge, 
colored or otherwise, or auy offensive smell, she should at once 
present herself to the doctor for examination. 

5. The daily use of a vaginal injection of tepid water, or of 
some mildly astringent wash, will have the most beneficial effect 
in arresting the first symptoms of vaginal irritation. If the 
patient be wearing a Hodge pessary, she should be warned to use 
gentleness in introducing the pipe of the syringe, lest the instru- 
ment might be displaced. A patient need not be afraid of using 
an injection of simple warm water, even during the menstrual 
flow. This conduces very much to her comfort at the time, and 
the retention of any of the catamenial fluid is very apt to prove 
a source of irritation. 

6. If the vulva is much dilated from procidentia of the womb, 
it is well to keep the patient in the horizontal position for some 
days, whereby the womb will be kept up, and the vaginal orifice 
have time to contract before the introduction of the pessary, for, 
although the introduction of a disc or globe pessary may be ac- 
complished with great facility, its removal afterwards may be- 
come a matter of great difficulty, owing to the contraction of the 
vaginal orifice, consequent upon the womb being kept in situ, 
and no longer distending the parts. 

HOSPITALS OF PARIS. 

A local treatment of prolapsus uteri has been recommended by 



186 DISEASES OF THE UTERUS AND ITS ANNEXES. 

some Parisian surgeons. (La France Medicate, July, 1879.) The 
surgeon takes pure tannic acid and makes a concentrated solution 
of it in water, at the moment of using it. A score of little balls 
of charpie are made, and are allowed to soak thoroughly in the 
solution. A brush (camel's-hair,) with a long handle, is to be 
in readiness. The woman being in a suitable position, a specu- 
lum is introduced into the vagina, which reduces the uterus, or 
the reduction may be effected before its introduction. The brush 
is then dipped in the tannic acid solution, and being carried 
through the speculum, the uterine neck and the whole internal 
surface of the vagina is several times freely bathed, the specu- 
lum being withdrawn little by little, but re-introduced after- 
wards to pack the balls of charpie soaked in tannin in the uter- 
ine culs-de-sac, by means of a long pair of dressing forceps. 
The culs-de-sac are thus firmly packed, and the speculum being 
gradually withdrawn, the whole cavity of the vaginal canal is 
filled with these same balls, and the vulva is closed by a charpie 
tampon, which is externally supported by a compress. Complete 
rest in bed is observed, and twenty-four hours after its applica- 
tion the charpie is gently withdrawn, pellet by pellet. Cold va- 
ginal injections, composed of a strong decoction of dried oak 
bark, are then prescribed, to be used three times a day. Before 
each of these injections the womb should be restored to position. 
At the end of two or three days at most, this operation is re- 
peated, and so on, increasing little by little the intervals between 
the applications of the dressings ; and even after it is thought 
that a cure has been obtained, the injections alone should be con- 
tinued for fifteen days or so. 

The proceeding is very simple, inexpensive, applicable at all 
times and in all places, necessitating neither special apparatus 
nor substances difficult to procure, nor traumatism of the genital 
organs ; it is entirely painless, very easy of application, even for 
the most inexperienced physician, and secures at the end of some 
months an absolute and veritable cure of uterine prolapse. 



DISPLACEMENTS. 1 87 

PROF. ELLERSLIE WALLACE, M. D., PHILADELPHIA, 

Employs a curved sponge-tent, reinforced by a steel spring. 
The spring is introduced within the interior of the tent, and by 
its tendency to resume its original form after being bent in the 
reveise direction, acts to lift up the bent womb. The theory is 
not that of effacing the curve by dilatation, but the principle is 
that by the erection of the tent, by virtue of its elasticity, the 
curve of the uterus is effaced by the gentle, yet powerful action 
of the tent as a lifting force, which elevates the fundus of the 
uterus from its abnormal position. The first tent should be of 
small size and without a spring, because the bulk A the sponge 
would not be sufficient to hold the spring to its proper curve. 
In making these tents, the sponge should be elastic and moder- 
ately close-grained. A cylinder, free from large cavities, is to 
be cut from it, corresponding in length to the uterine cavity, and 
having in its long axis a gentle curve, similar to the natural 
bend in the womb. This cylinder is to be a little thicker than 
the thumb, but may vary in proportion to the effect desired. 
Wash it well, and trim it smoothly. Next, make an opening in 
the centre from one end almost to the other, and pass into this a 
piece of watch-spring half an inch shorter than the tent, and 
with an eye at each extremity. The spring is fastened by a silk 
thread passed through the sponge and the eye, around the cylin- 
der and again through the eye, and tied tightly. The other end 
of the tent and the eye are transfixed by a stout needle. The 
tent is then soaked in a thick solution of gum acacia, then 
wrapped closely with strong twine from one end to the other. 
It may now be moulded into any desired curves. A sound bent 
to the shape of the uterine cavity is laid on a piece of wood, and 
its course marked by tacks. The moist tent is then put into the 
place of the sound, and allowed to dry there. The needle indi- 
cates the position of the spring. 

The hard dry tent is removed and the twine unwound. It 
must now be smoothed by fine sand-paper and the end beveled, 
but not to a point. Rub it with wax and burnish it with any 



188 DISEASES OF THE UTERUS AND ITS ANNEXES. 

hard instrument. It is completed by passing a string through 
the opening occupied by the needle. This is for convenience of 
extraction, and also aids in securing the spring in the centre of 
the tent. As a rule, three curves will be all that will be re- 
quired. Those most used are a moderate curve, only a little 
more than the natural uterine bend ; a fish-hook curve for ex- 
treme cases; and an intermediate one, which will probably be 
most required. 

ALBERT H. SMITH, M. D., PHILADELPHIA, 

Has materially and usefully modified the lever pessary of Prof. 
Hodge. He lengthens the closed lever so that its length is about 
twice its width ; he makes it ovoidal, with the apex in front, 
curves the anterior bar from above downward, and curves the 
posterior bar upward. He claims that it is easily retained in 
place, its length and ovoidal form adapting it to the shape of the 
vagina, which is connoidal, with its base toward the vaginal cul- 
de-sac, while, on the contrary, the rectangular pessary cannot be 
accommodated and retained ; the curvature of the posterior bar 
takes away the sharp angles behind, and the centre of the bar 
resting directly behind the lower portion of the body of the 
uterus, allows it to hang over it, suspended by its vaginal attach- 
ment, without undue pressure upon the vaginal tissues, as from 
the straight bar the depression of the anterior bar rounds off the 
corners which rest against the vagina, and relieves the urethra 
from pressure. 

Dr. S. claims as the merits of the lever pessary its ease of 
introduction ; its deriving its support from the floor of the 
pelvis, making no tension of the vagina, acting as a true lever, 
its fulcrum being the pelvic floor, the weight — the uterus — 
resting upon the short arm, and the power acting on the long 
arm, being the elasticity of the anterior vaginal wall, the weight 
of the intestines, and the action of the abdominal muscles ; 
these two latter forces, which would operate upon the uterus to 
keep it displaced, being utilized to elevate it; preserving the 



DISPLACEMENTS. 189 

natural mobility of the uterus ; making no pressure on the neck, 
acting so as not to interfere with the functions of reproduction, 
Perhaps not the least useful relief is that noticed by pregnant 
females when wearing this pessary — the absence of extreme 
nausea. Dr. Smith believes this point is one calling for clinical 
study. 

EUGENE C. GEHRUNG, M. D., ST. LOUIS, 

Has invented a pessary which strongly resembles a Hodge 
closed pessary folded on itself. The two arches thus formed 
rest against the anterior wall of the vagina ; the lower one resting 
near or upon the os pubis, according to the degree of tonicity of 
the vagina, from which point it derives its anterior support. 

The lower branches of the lateral curves rest on each side of 
the vaginal aperture, in an antero-posterior direction on the 
vaginal surface of the perinseum. These prevent the instru- 
ment from rotating on the transverse and antero-posterior axis. 
An additional support is gained by the contact with the elastic 
vaginal walls and their close co-aptation to and insinuation 
between the arches and curves of the pessary. It rests within 
the vaginal grasp as a segment of a solid cylinder would rest in 
the grasp of an elastic one. Hence there is no obstruction of the 
vaginal space. The distance between the two arches varies from 
1 J to 1J inches. The antero-posterior and transverse diameters 
vary as the size of the instrument. 

The pessary is introduced with the patient on her back, the 
knees well flexed and separated ; and the curves so placed that 
the instrument shall rest in the position at first described. 

Dr. Gehrung claims that few cases of anteversion can resist 
its action, when well fitted, unless firm adhesions confine the 
womb to the Unnatural position. It has no fixed points of 
resistance, is supported everywhere, and allows free motion to 
the womb. It is simple in construction. It is inelastic, and 
hence its operation is under perfect control. Its material is such 
that it can readily be modified to suit. It does not interfere 
with marital relations. It is easily introduced and removed, 



190 DISEASES OF THE UTERUS AND ITS ANNEXES. 

and it causes no obstruction to the rectum, or bladder, or 
pressure anywhere. 

The anteflexion pessary is the same pessary with the addition 
of a slightly excavated and inclined blade or shield. It supports 
the body of the womb, and compels the neck to retain its proper 
position and thus straightens it. 

For retroversion and later o-version the pessary is the Hodge 
pessary, with the addition of an arched blade or shield con- 
necting the two lateral branches into a solid body for the 
distance of 1J inches. It acts by replacing the body and 
preventing the neck from following its motion to an abnormal 
position. 

Dr. G. calls this form the retroflexion pessary, and sums up as 
follows: "This pessary combines the several qualities of a retro- 
version, retrolatero-version, retroflexion, and retrolatero flexion 
pessary, and in addition the quality of protecting, especially the 
rectum from cervical compression, and the womb from being 
thrown into complete ante version." 



NON-MALIGNANT GROWTHS. 

T. GAILLARD THOMAS, M. D., NEW YORK. 

Polypi. The treatment is palliative or curative. The first is 
necessary where the conditions are unfavorable to the immediate 
attempt at a radical cure. If practicable, manipulation should 
be delayed until the tumor is expelled into the vagina. Use 
palliative treatment to replace the womb if displaced, and main- 
tain it by a proper support, removing all pressure from above ; 
keep the patient in bed at her periods, giving only cold and acid 
drinks, and administering cannabis indica, opium, gallic acid, 
ergot, or aromatic sulphuric acid. After the epoch has lasted 
four days, apply a tampon with solution of alum or tannin ; 



NOX-MALIGNANT GROWTHS. 191 

keep the bowels regular and avoid fatigue; give nutritious food, 
bitter tonics, and nervines as they may be indicated, but avoid 
the use of iron, which increases the hemorrhagic tendency. At 
bed-time, during the interval, syringe the vagina with tepid 
water, and insert a suppository of tannin high up. 

The curative treatment will be to remove or destroy the tumor. 
If the canal has been dilated by the polypus, the walls may be 
slit on each side nearly to the vaginal junction, and the tumor 
drawn out by a tenaculum. Or complete dilatation may be 
secured by means of tents, and the tumor may be aided in its 
exit by the use of ergot. If it become necessary to seek the 
pedicle near the fundus, it may be severed by excision, torsion, 
ligature, ecrasement, the galvano-caustic wire. If within reach 
of the knife or scissors, it may be divided. When higher up, 
Simpson's polyptome comes into use. Small growths may be 
scraped off by the curette, or twisted off with the forceps. The 
ligature is objectionable ; ecrasement is better. For this, Hicks' 
wire rope ecraseur is excellent. A hard, fibrous polypus, too 
large for its pedicle to be reached, may be cut away piecemeal 
by a curved scissors or Nelaton's forceps ; or destroyed by deep 
incisions into its mass. When possible to encircle the pedicle 
with the galvano-caustic wire, this instrument is preferable. It 
cuts without force, and there is no hemorrhage. 

LOMBE ATTHILL, M. D., DUBLIN. 

Mucous polypi are best removed by the wire loop twisted, or 
by the ecraseur. In all cases, the seat of origin must be cauter- 
ized with nitric acid. He passes the wire, in cases where the 
mass is attached to the fundus, by means of two slender silver 
tubes like those known as "Gooch's canulse." When these 
reach the base of the tumor, they are separated and one is passed 
around, carrying with it the wire. The canulse are then passed 
through openings in the extremity of the ecraseur, the wires 
attached, and drawn tight until the tumor is cut off. 



192 DISEASES OF THE UTERUS AND ITS ANNEXES. 

THOMAS ADDIS EMMET, M. D., NEW YORK, 

Has invented an ecraseur for the removal of these growths. He 
preferred a chain to the wire, and finding that this would break, 
and as the curved ecraseur did not always prevent this, he placed 
three joints at the end, so that it could be opened straight, or 
bent upon itself at a sharp angle. To facilitate the application 
of the chain, the ends were attached to two flat rods or bands, 
which could then be passed between the two halves of the ratchet 
portion, and secured at the handle by a spring catch. To aid in 
placing the chain close up around the base of the tumor, when 
situated high up, as at the fundus, he employs a copper sound, 
with a small circular eye at its end, or a flat piece of whalebone 
carefully rounded and smoothed, with an opening at the end. 
Through the eye or opening, a strand is passed with a loop, in 
which is included the chain. By this instrument, the chain is 
very readily carried up close around the point from which the 
mass springs. 

This author regards the curved scissors as equally applicable 
where they can be employed for the removal of these growths. 
He also uses what he calls his " enucleator," a curved steel plate 
with a saw-edge placed over the end of the index finger, and held 
in place by a band. With this he separates the tissues when the 
other means cannot be employed. A rule to be observed is, 
that when the pedicle is of small diameter, it may be cut close 
to the uterus ; but if short and broad, the separation should be 
made near the tumor, lest a partial inversion or indentation be 
caused. 

Where fibrous tumors are not pedunculated, he excites uterine 
contraction by traction on the growth toward the os uteri. This 
causes pedunculation by the crowding out of the tumor from its 
bed by muscular contraction behind. He prefers a cord with a 
slip-knot placed around the growth with which to make traction. 
It is of no importance as to the thinness of the uterine walls, as 
the contraction will close up the space as fast as the tumor is 
withdrawn. It is safer than enucleation, as it cannot be known 



NOX-MALIGNANT GROWTHS. 193 

how far the uterine tissue is involved. As a principle of prac- 
tice, he would delay surgical interference as long as possible ; 
but when the tumor presents at the os, the operation should be 
considered, for its appearance in the vagina will lead at once to 
the question of blood-poisoning. The operation once begun, it 
must be completed, as entailing least risk. The purpose is to 
excite uterine contraction, and this will be continued by traction 
on the tumor as it is removed piecemeal. The best means for 
removal is a pair of blunt-pointed scissors, cured on the flat. 
The ecraseur is not fitted for it, as it does not excite the contractions, 
nor is the mass so rapidly removed. After having removed the 
portion which first filled the vagina, follow as far as possible the 
uterine canal. The after-treatment will be to wash out the cavity 
thoroughly with hot water, and then apply freely Churchill's 
strong tincture of iodine. This arrests the oozing, and is a 
valuable antiseptic. Never introduce the subsulphate of iron 
into the cavity, as it is not astringent, and only fills it with co- 
agulated blood, to decompose and cause blood-poisoning. After 
the iodine, a little cotton saturated with .glycerine may be packed 
in, and we may even fill the cavity with cotton damped with a 
strong solution of alum. Remove this on the second day, and 
if bleeding has ceased, omit all dressings, and merely wash 
freely with warm water, and if there is decomposition, add a 
little brewer's yeast or carbolic acid. 

Fibrous growths are to be removed when it can be done with 
a reasonable degree of safety, or their development arrested and 
the patient's strength preserved by checking the loss of blood. 
A cardinal rule is not to destroy the vitality of the tumor in situ, 
lest we add the risk of blood-poisoning. Hence, the action of 
hot water injections, iodine, and ergot, will be beneficial. The 
latter must be used only in small and repeated doses, to excite 
moderate contraction. It is only to be used in large doses when 
the os is dilated and it is believed that the tumor is ready for 
removal. The watery extract of ergot, in the proportion of 
three parts to about seven of water and the same quantity of 
glycerine, may be used subcutaneously. 

13 



194 DISEASES OF THE UTERUS AM) ITS ANNEXES. 

Dr. Ephralm Cutter, of Boston, proposes a carefully regu- 
lated diet, chiefly of animal food, and in a number of cases there 
was observed a marked decrease in the tumors. 

The general treatment should be to improve the health. The 
patient should be in a recumbent position during menstruation, 
but at other times she should be as much as possible in the open 
air. Iron seems to increase the hemorrhage, but the action of 
sunlight on the skin will tend to obviate this. Constipation 
must be avoided. Food should be in the concentrated form, 
leaving little for excrement or to cause flatus. Inspissated ox- 
gall will aid in relieving constipation. As the tumor increases, 
it should be gotten out of the pelvis, lest it cause disturbance by 
pressure. Displacements are to be relieved by mechanical 
support. 

To control the hemorrhage, position is very important, even 
keeping the pelvis above the level to check the flow toward the 
organs. Ergot cannot be relied on ;. it rather increases the flow, 
and should only be used in the intervals as above. Opium allays 
local irritation, quiets the circulation, and secures contraction of 
the capillaries. It is best given by the rectum. Gallic acid and 
cinnamon may be given, a drachm of the former rubbed up in 
an ounce of simple syrup; then add four ounces of cinnamon 
water and three of pure water ; dose, a tablespoonful every two 
or three hours. If this cause nausea, dilute it more, diminish 
the dose, and lengthen the interval. Drs. Churchill and 
McClintock highly recommend tincture of cannabis indica in 
ten-drop doses three times a day. McClintock gives l/ 16 
grain of bichloride of mercury every six hours. The only re- 
liable means are local applications : hot water injections, tinc- 
ture of iodine, dilatation of the canal if necessary, and, above 
all, a tampon of cotton saturated with solution of alum, or one 
of oakum. By means of the applicator, a tuft of cotton, loaded 
with Churchill's tincture of iodine may be applied to the 
fundus, and allowed to remain until forced out. By means of a 
projecting end, it may be removed if required. The iodine may 
be injected by a hard rubber syringe, with the end properly 



NON-MALIGNANT GROWTHS*. 195 

curved. The nozzle is to be carried up to the fundus like a 
probe, and the iodine forced out very slowly, the patient lying 
on her left side, with a sponge at the os to prevent the escape to 
the vaginal walls, which it would greatly irritate. When tie 
strength is not too much exhausted, she should be placed on her 
knees and elbows, with the os exposed by the speculum during 
the injection. This generally promptly arrests the hemorrhage. 
The amount injected should not exceed a drachm. In the ab- 
sence of the long-nozzled syringe, a flexible catheter may be 
carefully passed up, and the injection thrown in by means of a 
glass syringe. To increase the action of the iodine, hot water 
irrigation should be used. A rubber bag may be introduced on 
the point of the sound, and then filled with water, thus making 
direct pressure on the bleeding surface. 

Surgical measures are the division of the cervix and the de- 
struction of the tumor. Yelpeau, Amussat and Sims enucle- 
ate or tear these tumors from their beds. The late Dr. Atlee 
took out a section, and thus destroyed the vitality. Simpson 
introduced caustic within the mass. 

G. DE GORREQUER GRIFFITH, L. R. C. P., LONDON, 

Puts the patient to bed and keeps her there, thus securing quiet 
in every way (ObsL, Jour., G. B. & I., March, 1878); cleanses 
the bowels, and two days after dilates the os and cervix with a 
sea-tangle tent to a point short of occasioning much pain. Be- 
hind the tent, he inserts a tampon of cotton-wool soaked in 
iodine and glycerine, or glycerine and Condy's fluid. At the 
end of two days, a great watery discharge issues from the vagina ; 
the tampon may be slightly tainted ; the os will be spongy and 
soft. The vagina must be well washed with a disinfectant. At 
the end of a second day, a larger tent is used, and so repeated 
till the os and cervix admit two fingers. Thus he disperses 
small intra-mural fibroids, situated in the lips of the os, in the cer- 
vix, or even at the fundus, and malposition is often corrected. 
Intractable cases require more dilatation, and often painting the 



196 DISEASES OF THE UTERUS AND ITS ANNEXES. 

os and cervix with the acid nitrate of mercury ; or in slow cases, 
he packs the interior of the uterus with pellets of cotton-wool 
soaked as above. This he repeats till the cure is effected, say 
every two days. Larger tumors require that the liquid mercury 
be swept lightly around the cavity by means of a wire and a 
packing of wool, as above. At the next sitting the mercury is 
more freely used, being well tolerated ; and finally he introduces 
a pellet squeezed out of the mercury, held in place by the tam- 
pon and left for two days, using at the same time, by the rectum, 
morphia suppositories. During this time, he gives ergot and 
strychnia, as they act on the enlarged and dilated womb and aid 
the dispersion. He even uses this plan where growths involve 
the womb itself intimately ; the shorter the pedicle, the more 
hopeful the case. 

Never pack the womb too full of the pellets, lest the pain 
they cause requires their removal. 

Latterly, he uses in place of the mercury, purified carbolic 
acid in crystals, or a saturated solution by the pellets, and packs 
the cavity below the os, and even the upper portion of the va- 
gina, with wadding steeped in glycerine. The carbolic acid 
allays the pain excited by the mercury, if they are used together. 
The acid causes the living tissue to blanche, dry and shrivel. 

The flow of serum from the vagina is remarkable, and may 
be taken for hemorrhage or even for an escape of urine. It is 
remarkable how rapidly fibromatous conditions were removed by 
the mere use of the dilating tents, with the ergot and strychnia. 
He explains this, that the tent has effected dilatation, expanded 
the os and cervix, thus causing direct pressure from within ; the 
fibres of the womb contract, and these two antagonistic forces 
diminish the blood supply, diminish the growth, and it is speedily 
obliterated. Of course, the acids, when used, act directly as de- 
structive agents. 



NOX-MALIGXAXT GROWTHS. 197 

THE MEDICAL TKEATMENT OF UTERINE TUMORS. 

DR. L. DE SIKETY. 

The radical cure is of course the removal of the tumor; but 
as this is often not attainable, we must have recourse to symp- 
tomatic treatment. This is principally to be directed against the 
metrorrhagia. The most available means are either cold appli- 
cations on the abdomen or else protracted vaginal irrigations. 
Some employ the latter hot, but this author prefers them cold. 
Astringent substances, as tannin or perchloride of iron may be 
added. If the hemorrhage is very abundant, the tampon must 
be applied, and compression of the abdominal aorta. Occasion- 
ally the hemorrhage ceases after deep incisions at the cervical 
orifice. This is to be explained by the diminished congestion of 
the tissues thus brought about. Dilatation of the neck acts in 
the same way. 

Intra-uterine injections of astringents are dangerous, and 
should not be resorted to. 

The ergot of rye is the most efficient agent in hemorrhage from 
fibrous bodies. It may be administered by the mouth or sub- 
cutaneously. The combination he prefers is the following for a 
hypodermic injection of ergotin : 

168. R . Ergotinae (Ronjean's), gr. xxx. 

Aquae destillatse, 

Glycerinse purse, aa f.^ss. M. 

Twenty drops every day, or every other day. 

If care is taken to inject in the cellular tissue, and not in the 
dermis, there is little danger of accidents. 

Of all the means alleged to favor dispersion of fibrous tumors, 
ergot is the only one on which Dr. DE S. can place any depend- 
ence. 

For the relief of periodically recurrent pains, due to these 
tumors, local bleedings, together with narcotics, are indicated. 
Sometimes when the pains arise from pressure of the mass ou 



198 DISEASES OF THE TJTEKUS AND ITS ANNEXES. 

nerve trunks, a well-fitting pessary will lift the mass and give 
relief, or a hypogastric belt, accurately adjusted, will often 
answer. 

DR. J. DE LA FAILLE, OF LEUWARDEN, HOLLAND. 

In regard to the treatment of the fibrous variety of tumors, 
(his practitioner read a paper at the International Medical Con- 
gress of 1879, expressing the following conclusions: 

1. The treatment of uterine fibromata is principally deter- 
mined by the hemorrhage. 2. The treatment must be modified 
with respect to the size and seat of the tumor. 3. Internal 
medication is seldom successful, though it may be tried in cases 
of intra parietal fibromata. The same may be said of alkaline 
baths. 4. A very rational treatment of intra parietal fibromata 
consists in subcutaneous injections of ergot. 5. The usual 
method of dilating the uterus, by means of sponge tents or 
laminaria tents, is dangerous. It is important that the tents 
should be frequently renewed. 6. Fibrous polypi ought always 
to be removed with the ecraseur. 7. Intra- uterine fibromata 
are best removed by enucleation. The same may be said of the 
sub-peritoneal fibromata. 8. In cases of gastro-hysterotomy, the 
intra-peritoneal treatment of the pedicle is preferable to the extra- 
peritoneal treatment. 9. The extirpation of the uterus in toto is 
preferable to the partial excision of the organ. 10. Ovariotomy 
is very seldom indicated in fibrous tumors of the womb. 

Dr. Cotjrty, of Paris, has frequently urged the medical treat- 
ment of uterine fibro-myomata. In a- recent paper presented in 
1 880 to one of the Parisian societies, he stated that he relied on 
the following methods : 

1. Injections at as high a temperature as the patient could 
bear (about 113° F.) of water mixed with carbolic acid at the 
rate of twenty-five grammes per litre ; this was an excellent con- 
gestive and anti-hemorrhagic means. 

2. Subcutaneous injections of ergotin. 



NON-MALIGNANT GROWTHS. 199 

3. The electronic action of the continuous current applied 
by regulated intemiittences with a metronome. 

M. Couety was of opinion that good results were certain if 
this method were used in the treatment of uterine fibro-myomata. 

M. Verneuil believed that this method was only successful 
in about a third of the cases treated. Excellent in cases of 
fibroma of the congestive type, it had no effect on old-standing 
fibromata. In cases where profuse hemorrhage was noted, and 
in which one or two painful points were found in the tumor cor- 
responding to the ovaries, subcutaneous injections of morphia 
soothed the pain, and also arrested the hemorrhage. 

M. Court Y allowed that cure could not always be obtained, 
but said that his method procured, in every instance, real and 
considerable relief of the suffering. 

Other means for arresting the hemorrhage have been suggested 
by Dr. A. Gusserow. (Deutsche lied. Wochenschrift, 1880, 
No. 22.) He injects into the uterine cavity, after dilating the 
cervix, w r eak solutions of muriated tincture of iron or of tinc- 
ture of iodine. These measures should not be repeated too often, 
at most twice a week, and should be suspended at once if the 
uterus becomes sensitive, or a serous, bloody discharge is brought 
on, for fear the tumor will become gangrenous. 

Fibroid Tumors. From numerous sources, lately, the assertion 
has been made that interstitial fibroid tumor of the uterus can 
be treated hypodermically by the aqueous solution of ergot, with 
eminently more satisfactory results than by any other mode of 
treatment, or by operation. 

169. R. Ergotinse (Bonjean's), gj. 

Glycerinse, f-.^j- 

Aquse destillatse, £^j- M. 

Inject twelve drops daily, hypodermically. 

Dr. Byford prefers Squibb's fluid extract to any other form 
of ergot, and Dr. Atthill recommends the omission of the 
glycerine, and prefers a solution of one part of the extractum 
ergotse liquidum (British Pharmacopoeia) in two of water, inject- 



200 DISEASES OF THE UTERUS AND ITS ANNEXES. 

ing fifteen or twenty minims of this each time. He always in- 
serts the needle into the gluteus muscle, making it penetrate to 
the depth of more than an inch. 

Dr. J. W. Walker, of Indiana, has reported success from 
the use of the ergot of maize, the ustilago maidis. (New Prepar., 
Jan., 1878.) 

Dr. Byford adds some further directions on the ergot treat- 
ment in an article in the Chicago Medical Journal and Examiner, 
Oct., 1879. The mode of administration should be governed by 
the objects to be attained. If we desire to cause the painless 
absorption of the tumor, the doses ought to be moderate in size, 
and not too frequently administered. Hildebrandt adminis- 
tered by hypodermic injection a preparation in quantities which 
represented from fifteen to twenty grains of the crude drug once 
daily, or once every other day ; and it will often be sufficient 
once a week. If we desire to have the tumor expelled, we 
should administer full and increasing doses, often repeated, and 
continued until the object is attained. 

It will sometimes be necessary to vary the quantity and times 
of giving it, to suit the susceptibility of the patient; less or 
more, according to the amount of pain caused by it. 

It is not essential to give it hypodermically, although when it 
does not produce much inconvenience, this is a very efficacious 
method ; it may be given by the mouth, in suppositories, per 
rectum, etc. 

When we administer ergot for the cure of fibrous tumors of 
the uterus, the beneficial action of the drug will depend upon 
the degree of development of the fibres of the uterus, and the 
position of the tumor with reference to the serous or mucous 
surface. The nearer the mucous surface, the better the effects. 
If the tumor is very near the lining membrane, we may hope 
for its expulsion en masse, or by disintegration. 

We can often select the cases in which good results may be 
expected. There are four conditions which are usually reliable 
for this purpose. They are, smoothness of contour, hemorrhage, 
lengthened uterine cavity, and elasticity. A smooth, round 



KON-MALIGXANT GROWTHS. 201 

tumor denotes, for the most part, uniform textural development; 
hemorrhage, a certain proximity to the mucous membrane; a 
lengthened cavity, great increase in the length and strength of 
the fibres; and elasticity assures us of the fact that cartilaginoid 
or calcareous degeneration has not begun in the tumor. 

An even, nodulated tumor maybe composed of many separate 
solid masses. These displace and^ prevent the growth of the 
fibres to such an extent as to render contractions inefficient. 
When hemorrhage is not present, the tumor is probably near the 
serous surface, and consequently not surrounded by fibres. 

Uterine Polypi. The chloride of calcium, once popular as a 
remedy for goitre, has recently been advocated by various 
Irish physicians as efficient in bringing about the expulsion of 
uterine polypi. (Irish Hospital Gazette, Sept. 15th, 1874.) The 
formula is : 



170. R. Liquoris calcii chloridi, f«3iv. 

Tincturse ferri chloridi, 

Spiritus chloroformi, aa f. ^ j. 
Tincturse aurantii, f-.^ij- 

Infusi calumbse. f.^ vij. M. 

Two tablespoonfuls three times a day. 



These polypi can also, in many instances, be expelled by the 
administration of ergot, either by the mouth or subcutaneously. 
In the hemorrhage which accompanies these growths, perhaps 
the best injection is of solution of subsulphate of iron, as follows : 



171. R. Liquoris ferri subsulphatis, f.Hjss. 

Aquae, t% ij. M. 

To be used for intra-uterine injections. 



This strength cannot be exceeded with safety, and frequently 
one-half the amount of the salt will be sufficient. 

Prof. Jones, of the Medical College of Georgia, and other 
Southern physicians, have claimed that the free administration 
of muriate of ammonia brings about the discussion of fibroid 



202 DISEASES OF THE UTERUS AND ITS ANNEXES. 

tumors of the womb, hypertrophic contractions of the uterine 
walls, and allied troubles. It may be alternated with ergot. 

In coxcomb granulations of the os, the best application is 
strong cider vinegar, or crude acetic acid. It may be poured into 
a speculum and allowed to cover the diseased portion for about 
five minutes. This should be repeated every other day. Nitrate 
of silver is liable to excite hemorrhage if applied to this form 
of erosion. 

In simple ulceration of the os much good often follows the 
use of iodo-tannin : 

172. R. Iodinii, ^j. 

Acidi tannici, f.^j. 

Aquse, Oj. M. 

Filter and evaporate to 5 iv. To be applied to the ulcerated surface. 

Or, for extemporaneous use : 

173. R • Tincturse iodinii, 

Tincturse gallse, aa f. * ss. M'. 

For local use. 

J. T. Everett, M. D., (American Journal of Obstetrics, Jan- 
uary, 1878,) concludes, from his notes of cases, that: 

1st. A judicious use of the faradic current is as certain and 
powerful to produce uterine contractions as ergot. 

2d. It is more easily controlled. 

3d. It does not disturb nutrition, or any of the secretions, nor 
does it interfere with digestion. 

4th. It does not induce pain in distant organs, and is not fol- 
lowed by cephalic disturbance or nervous shock. 

5th. It does not give rise to inflammations, or produce other 
local injuries. 

Dr. Robert Bell, London, reports in the Lancet, Feb., 1879, 
several cases successfully treated with ergotine suppositories. 
These contained each four grains, and were inserted each night, 
resulting in the expulsion of the tumor. 



XOX-MALIGXAXT GROWTHS. 



203 



F. A. GALLOIS, M. D., PARIS. 

174. R . Morphia? inuriatis, g j.-ij. 

Sacchari, gr. iv. 

Cerae albse, £j. 

Butvri cacao. 3 ss. M. 

Melt over a slow fire the- cocoa butter and wax, incorporate the sugar and 
morphia, carefully triturated together, and when tJie mixture is on the point 
of forming & mass, run it into four horns of paper, and allow it to cool. 

These vaginal suppositories are useful in painful affections of 
the uterus, rectum, and bladder. 

KESUME OF EEMEDIES. 

Ammonil Murias. Both Drs. W. L. Atlee and E. E. Peas- 
lee have witnessed disappearance of uterine polypoids 
from the long-continued administration of this agent, 
gr. x., thrice daily. It is best given in the form of 
compressed pills. 

Calcii Chloridum. This was recommended by Dr. McClintock. 
(See F. 170.) Dr. Tilt gives gr. x. twice daily. He 
remarks that its effects are more positive after the 
change of life, and adds the caution that its long- con- 
tinued exhibition has been known to cause arcus senilis 
and other evidences of arterial degeneration. 

Cannabis Indica and 

Digitalis, as anemiants of the reproductive organs, have some 
claims to consideration as checking the development of 
new growths. 

Ergota. The exhibition of this may be either (1) by the mouth ; 
(2) by the hypodermic injection ; (3) by suppositories. 
(See p. 199.) When given by the mouth, Goodell 
believes its permanent effect is enhanced by combina- 
tion with iodide of potassium or ammonium chloride. 
The os should be dilated at the same time. Prof. 
Hildebrandt proposed daily hypodermic injections of 
the aqueous extract under the skin around the umbili- 
cus. He uses: 



175. R. 



Ergotinse, 

Glycerinse, 

Aquee, 



6 parts. 

15 parts. M. 



204 DISEASES OF THE UTEEUS AND ITS ANNEXES. 

Successful cases have been reported in Philadelphia 
by this means, one by Dr. W. V. Keating, who uses : 

176. B= . Ergotinse, gr. xlv 

Glycerinse, 

Aquse destillata?, aa Tr\_cv. M. 

Prof. John Ashuest, Jr., employs : 

177. R . Ext. ergotre fiuidse, f. % iss. 

Glyceriuse, f-.^j- 

Aquae, f.gij. M. 

Of either of these ^ xx. is a sufficient injection : 
the nozzle of the syringe should be carried down to 
the muscular walls of the abdomen in order to avoid 
the formation of abscesses. Rectal and vaginal sup- 
positories of about gr. x. each of the solid extract are 
used by some. The use of ergot is not wholly with- 
out danger, as some persons are greatly nauseated by 
it, have headache, etc. (Goodell, Trans. Med. Soc, 
Pa., 1880.) 

Ferrum in various forms may be advantageously used to combat 
the anaemia. Goodell combines it with ergot. 

Gallicum Acidum stands next to ergot as a hemostatic in poly- 
poid hemorrhages (Goodell.) 

Hydrargyri Biniodidum. Goodell records the marked diminu- 
tion of a very large fibroid after long-continued frictions 
with an ointment composed of gr. viij. of the mercuric 
biniodide to lard § ss. 

Hydrargyri Chloridum Corrosivum. Drs. T. M. Madden 
and Routh, of London, report cases where this agent 
appears to have diminished uterine polypoid growths 
in a marked degree. (Half- Yearly Compendium, July, 
1874.) 

Iodinium. In the medical treatment of uterine polypi, Dr. T. 
M. Madden states that he has found the long-con- 
tinued use of small doses of tincture of iodine service- 
able. 

Potassii Bromidum is spoken of with decided favor by Simpson 
and Galabin, but doubtfully by Goodell. It should 
be continued for months in moderately full doses. 

Potassii Iodidum has a certain amount of testimony in its favor, 



NON-MALIGNANT GROWTHS. 205 

for reducing uterine polypoids. Goodell combines it 
with ergot. 

Sclerotic and Sclerotinic acids have been employed for injection 
into the substance of fibroids. Dr. John Williams, 
of London, has reported two cases in which the former 
promptly checked the hemorrhage and reduced the 
tumor. 

Sulphurieum Aclchun. In the bleeding from uterine fibroids, 
Goodell recommends : 

178. R. Quinise sulphatis, gr. ij. 

Acidi sulphurici aromatici, gtt. xx. 

Aquae, q. s. M. 

For one dose every two hours. 

Ustilago 3Iaidis, the ergot of maize, is said to act similarly to 
that of rye. 

Vinca Major is praised by Mr. Spencer Wells, as an efficient 
agent to combat the anaemia and debility following 
hemorrhagic tumors. An effusion of § ij. of the leaves 
to f. I xx. of boiling water, f. § ij. every three or four 
hours: or, f. 3j. of the fluid extract, are the proper 
doses. 

OTHER MEASURES. 

Baths, containing bromine and iodine, taken in connection with 
the internal administration of these agents, are com- 
mended by Gala bin. 

Electrolysis has been highly lauded by some authorities. (P. 199.) 
Its claims are not yet made out. 

Galvanism. The constant galvanic current has caused in some 
instances retrogressive changes in fibroid uterine tumors. 
Goodell speaks of it as an agent from which in the 
future much may be expected. 

Leeches. Dr. Tilt observes that even bad cases" of uterine 
fibroids may be greatly improved by hygiene, by saline 
purgatives, and by the application to the cervix of two 
or three leeches, just before menstruation. 

Mineral Waters, especially those of Kreuzuach ami Woodhall 
Spa, containing bromine or iodine, are believed to be 
valuable. Prof. A. R. Simpson says : " I have seen 



206 DISEASES OF THE UTERUS AND ITS ANNEXES. 

patients who were suffering from such tumors in whom 
the symptoms were relieved, and in whom the growth 
of a previously increasing tumor was arrested, if the 
bulk was not immediately diminished. These mineral 
waters seem to me to exert some portion of their influ- 
ence by acting as sedatives to the sexual organs, lessen- 
ing the activity of the circulation in them, and so 
reducing the nutritional activity." 
Pressure, by a firm, broad, elastic bandage retained by a perineal 
strap, will give great relief in some cases. 



MALIGNANT GROWTHS. 

DR. L. DE SINETY. 

In estimating the value of alleged cures of uterine cancer, this 
French professor rejects all pretended to have been brought 
about by arsenic, conium, iodine, etc. He believes that all these 
rest on errors of diagnosis, and that the supposed cancer was a 
benign neoplasm. 

Nor has he any more faith in any of the caustics, as the acids, 
potassa, chloride of zinc, bromine ; nor in electrolysis ; nor in 
the intra-parenchymatous injections advocated by Kiewtsch and 
Gallard ; nor in the amputation of the neck, which is almost 
sure to be followed by a relapse. In fact, the treatment reduces 
itself to palliating the symptoms, and prolonging life a little by 
temporary expedients. 

To relieve the pain the only really efficient agent is morphine. 
This should not be given by the mouth, but subcutaneously, the 
place of election being the exterior aspect of the .thigh, near the 
great trochanter, the cutaneous sensibility there being obtuse. 
Small doses should be used at first and increased later as 
required. 

The hemorrhage may be reduced by irrigations of cold water 



MALIGNANT GROWTHS. 207 

medicated with perchloride of iron. Internally the following is 
useful : 

179. R . Extracti ratanhise, gj. 

Chloral hydrati, % ss. 

Syrupi simp., 5j. 

Aquae menth., ^ iv. M. 

A tablespoonful from time to time. 

Ergot has little or no influence in these cases. When the 
hemorrhage is violent, tamponing is demanded. 

The vomiting and digestive troubles are best met by giving 
the food cold and in small quantities at a time. A milk diet, 
when practicable, is beneficial. For constipation and painful 
stools, laxative enemata are preferable to purgatives. 

During the whole course of this malady the strength of the 
patient should be supported by a good hygiene, the administra- 
tion of bark, and the moderate use of generous wines. 

E. J. TILT, M. D., LONDON, 

In flooding from cancer, scrapes away from the cervix the out- 
lying portion of diseased tissue, and applies the liq. ferri 
sub-sulph., or the fuming nitric acid. There is no cure. A fair 
trial should be given to the solution of iodide of arsenic and 
mercury, each drachm containing J grain protoxide of arsenic, 
and J grain of protiodide of mercury. Dose, half a drachm twice 
a day. It may cause marked improvement. Atlee had great 
faith in arsenic, in small doses for a long time, and locally a 
weak solution of iodine in glycerine. A drachm each of iodine 
and of iodide of potassium are dissolved in two drachms of gly- 
cerine, and applied by a brush, or on cotton, two or three times a 
week all over the cervix and to any part of the growth within 
reach. To relieve the pain, sedatives and anaesthetics. Ice to 
the neck of the womb is a palliative, also prolonged irrigation 
'with cold water. To destroy the odor, the chlorinated lime, one 
ounce to the pint of fluid, with a drachm of laudanum, and a 
tablespoonful of glycerine <o prevent irritation. A weak solution 



208 DISEASES OF THE UTERUS AND ITS ANNEXES. 

of carbolic acid is a good disinfectant. A good hemostatic is a 
strong solution of liq. ferri sub-sulph. thrown in with a sponge, 
allowed to remain in contact with the cancer, and then sucked 
up, and some cotton-wool saturated with a styptic left in contact 
with the sore, to be removed in a few hours. Repeat once a 
week. It does good in the worst cases, and may effect a cure in 
mild forms. If no other operation is admitted, remove by 
scraping all the softened tissue that can be done without causing 
too much pain or bleeding. 

WYNNE WILLIAMS, M. D., LONDON, 

Applies to the denuded surface, and also injects, a solution of 
twelve grains of bromine in a drachm of alcohol. Routh 
dresses the raw surface with gastric juice. It is best to remove 
the diseased tissues early with the knife. 



This author regards amputation of the cervix in cancroid of 
the os as valuable. It arrests bleeding and exhaustive discharges 
He prefers the ecraseur, or the scissors. He then applies per- 
chloride of iron in glycerine on lint to the cut surface, and plugs 
the vagina with wetted wool. Hemorrhage is to be checked by 
ice water injections into the vagina and rectnra ; perchloride of 
iron or tannin, the actual cautery, and plugging the vagina. Sir 
J. Y. Simpson extols the use of a saturated solution of per- 
chloride of iron in glycerine by means of a sponge to the sur- 
face. Tannin in fine powder, or tannic acid, may be applied 
through a tube or in form of a pessary. Cauliflower excres- 
cences may be broken off, and tincture of iron injected into the 
mass. 

Dr. Hicks found a saturated solution of alum, holding in 
suspense tannic acid, applied daily, very effectual. A sponge 
dipped in strong solution of nitrate of silver is equally valuable. 
To remove the offensive discharges, wash out frequently with 
solutions of disinfectants. For the pain, use opium, etc. It is 



MALIGNANT GROWTHS. 209 

found most effectual in the form of a lavement. The applica- 
tion of carbonic acid gas to the surface of the sore has been sug- 
gested. An ordinary quart bottle is used, with an elastic tube 
fitted to the cork. Eight drachms of carbonate of soda, and six 
of tartaric acid, are dissolved in water in the bottle, and the gas 
is generated. The vapor of chloroform may be mixed with it. 
Nutrition is important ; milk is a valuable article of diet. The 
urinary organs often require relief. For irritability of the blad- 
der, Vichy water, uva ursi, or pareira, with a little liquor 
potasssg, are useful. Sir H. Thompson suggests triticum repens. 



M. 



To lessen fcetor, add half an ounce of permanganate of potassa 
to a pint of tepid water, and inject twice a day ; or a weak solu- 
tion of carbolic acid, as an ounce dissolved in eight ounces of 
water, a tablespoonful of this to be added to half a pint of tepid 
water; or nitrate of silver, 10 grs. to the ounce, of which two 
or three ounces should be used each time. Internally, iron and 
arsenic ; preferably the tincture of perchloride of iron, or if the 
stomach is irritable, the ammonio-citrate. In cauliflower excres- 
cence, amputate the cervix, or destroy the growth by repeated 
applications of caustic potassa. 



Has never seen any benefit from the use of caustics in true 
cancer. He checks hemorrhage by the styptics already men- 
tioned, but prefers for this purpose the careful use of caustics so 
as to produce only a superficial slough, and thus temporarily 
seal the vessels. Every two or three weeks, after cleansing with 
cold water, touch the surface lightly by the actual cautery, acid 
nitrate of mercury, or pure nitric acid. Kelieve pain by opiates, 
and in many cases chloral will be found an excellent substitute 
or alternate for opium. Correct fcetor by the usual lotions of 
carbolic acid, one to two drachms to the pint, or the same pro- 

14 



210 DISEASES OF THE UTERUS AND ITS ANNEXES. 

portion of liq. sodse chlorinatse, or one drachm of powdered sub- 
sulphate of iron to the pint, or a weak solution of iodide of 
lead. Keep up strength by use of milk, beef-tea, etc. Use 
iron freely to repair damages, and quinine as a tonic roborant and 
an excellent remedy for the neuralgic pains. 

In epithelial cancer, the disease may be checked if not cured, 
by the entire removal of the diseased portion. If amputation 
be not advisable, cauterization should be performed so deeply as 
to destroy the surfaces by means of the cautery, potassa cum 
calce, or the acid nitrate of mercury. This will at least relieve 
pain, arrest hemorrhage, and restrain the discharges. He applies 
the potassa cum calce in the proportion of two parts of lime to 
one of caustic potassa. 



This writer announced in the Lancet, March 27th, 1880, a 
new cure for cancer of the generative organs, which attracted 
general attention, and has been reported on with some apparently 
favorable results. His original prescription is : 

180. R. Chian turpentine, gr. vi. 

Flowers of sulphur, gr. iv. M. 

Make two pills ; to be taken every four hours. 

No change was made in the diet or occupation, and no opiates 
were used. He says : " It is a most efficient anodyne, causing 
an entire cessation of pain in a few days, and far more effectual 
than any sedative I have ever given." 

DR. J. G. WESTMORELAND, OF ATLANTA, 

Maintains that no remedy in use has been equal to carbolic acid 
in the local treatment of cancerous ulcerations of the womb. 
[Atlanta Med. and Surg. Journal, Feb., 1880.) Applied to the 
ulcer in full strength, it is neither painful nor unnecessarily de- 
structive to tissue. Indeed, pain and irritability are relieved by 
it. What effect the remedy may have on the cancerous diathe- 



MALIGNANT GROWTHS. 211 

sis, if such exist, of course has not been determined, but that it 
will correct the condition of malignant ulcer, no one will doubt 
who has made thorough application of crystallized carbolic acid 
warmed to the liquid state. Used in this way, cancerous ulcer 
of the os, neck and vagina has been known kindly to improve. 
Being also one of our best antiseptics, the very offensive odor 
attending uterine cancer is promptly destroyed by it. The ap- 
plication every third or fourth day by touching with saturated 
cloth or sponge will give gratifying results to any physician who 
has the charge of such unpleasant and dangerous disease. 



This author, in cancer of the uterus, urges to operate without 
delay. When limited to the cervix, the scissors or knife is best 
with which to amputate, and by all means, if it can be done, get 
into healthy tissue. Healing the cut surface by granulation is 
liable to act adversely, by causing a renewal of the disease. It 
is better to cover the stump by sliding the vaginal tissue over it, 
and secure the edges of the flaps with sutures. Where the dis- 
ease has advanced too far for amputation, the actual cautery 
must be used. All the diseased tissue is to be scraped away 
down to a healthy surface if possible, and then the cautery ap- 
plied over the whole raw surface. The best is the thermo-cau- 
tery of Paqtjeltn. The platina is kept at a white heat constantly 
by forcing atmospheric air into the midst of a flame of benzine 
vapor. Next cover the surface with a thick pad saturated with 
glycerine, and a tampon over it if bleeding seems likely to occur. 
Let the pad be detached by suppuration. When this occurs, 
keep the vagina clean. Solution of thymol will no doubt be 
useful to correct the odor. To check the bleeding, should it 
occur, use a saturated solution of alum. Always use these solu- 
tions at a high temperature. Iodoform, one drachm to an ounce 
of lard, will relieve pain, correct fcetor, and diminish the dis- 
eased mass. 



212 DISEASES OF THE UTERUS AND ITS ANNEXES. 

PROF. E. S. DUNSTER, M. D., ANN ARBOR. 

In the Medical News, this author speaks very highly of 
chloral in these cases. He uses a solution of 10 to 30 grains to 
to the ounce, with which he saturates a cotton-wool plug, and 
applies it closely to the diseased surface. When required, it may 
be removed by means of a string attached to the plug. He 
claims that it corrects the odor, and also relieves the pains. 

DR. AUST. LAWRENCE 

Also recommends this remedy. He gives powdered ergot, 30 
grains every 6 hours, except when the patient is already reduced 
by loss of blood. 

[For a fall discussion of the medical, palliative and cauterant plans of 
treatment of Malignant Growths, see Naphey's Surgical Therapeutics, Chap- 
ter XIV. See, also, Sir Jas. Y. Simpson's treatment under head of Mam- 
mary Tumors, part II. of this volume.] 



STERILITY AND ANAPHRODISIA. 

These are separate conditions ; the former referring to infer- 
tility following the sexual act; the latter to the absence of the 
subjective and characteristic nervous sensations which constitute 
the sexual orgasm. As both conditions may depend on a great 
variety of causes, these must in all cases be carefully sought out. 

The causes of sterility are defined by 

T. GAILLARD THOMAS, M. D., NEW YORK, 

To be— 

1st. Causes preventing the entrance of the semen into the 



STERILITY AND ANAPHRODISIA. 213 

uterus, absence or closure of the vagina or uterus by an obdu- 
rator hymen, atresia, conical os, polypi, etc. 

2d. Causes preventing the production of a healthy ovule, as 
ovaritis, cellulitis, etc. 

3d. Causes preventing the passage of the ovule into the uterus, 
as stricture or obliteration of the fallopian tubes. 

4th. Causes destroying the vitality of the semen or preventing 
the fixation of the ovum, as endometritis, membranous dysmen- 
orrhcea, menorrhagia, abnormal growths, etc. 

Dr. Thomas adds : 

" In spite of the fact that we have at our disposal many val- 
uable resources for the removal of the causes which create 
sterility, were I asked to mention the part of the field of gyne- 
cology which yielded me the least satisfaction and the greatest 
disappointment, I should cite this." 

Where any obstacle is present, the proper surgical operation 
may be performed, as imperforate hymen, atresia vaginse, occlu- 
sion of the womb in any way. The affection is a symptom only 
to be reached through the malady causing it. 



This writer, in a paper on anaphrodisia, or, as he terms it, 
"impotency" in women (Am. Jour. Obstetrics, Jan., 1878,) sums 
up the causes and divides them into three groups • 
I. — Mental, subdivided into : 

a. Congenital psychical defects. 

b. Temporary mental conditions. 

c. Sexual incompatibility. 



II.- — General physical causes. 

a. Debility resulting from constitutional and other 

diseases not sexual. 
6. General defective development. 
c. Lactation. 



214 DISEASES OF THE UTERUS AND ITS ANNEXES. 

II. — Conditions of the sexual organs and near parts. 

a. Defective development and result of injury. 

b. Dyspareunia (Barnes), resulting from (1) uterine 

displacement; (2) hyperemia of the uterine 
body ; (3) ovarian inflammation or congestion ; 
(4) colpitis either simple -or specific; (5) spas- 
modic contraction of the vagina (vaginismus, 
Sims) ; (6) vascular tubercles of meatus urina- 
rius; (7) diseases of the rectum, as fistula, 
fissure, or inflamed piles or ulcers. 

c. Deranged nervous system from uterine displace- 

ments and other chronic uterine diseases, and 
debility from exhausting discharges and chronic 
uterine disease. 

d. Morbid growths. 

e. Delayed or arrested menstruation. 

The treatment of these conditions should, of course, be in the 
main etiological. 

GRAILY HEWITT, M. D., LONDON. 

This author gives as causes of this condition, abnormal condi- 
tions of the hymen ; narrowness or partial closure of the ostium 
vaginse, or vaginal canal; tumors interfering with intercourse, as 
an enlarged clitoris ; spasms of the ostium vagina? ; absence or 
imperfection of the uterus, chronic hypertrophy, closure of the 
os like a valve, one lip being larger than the other, flexions, etc. ; 
diseases of the ovaries ; altered conditions of the fallopian tubes ; 
ill-timed sexual intercourse, as women have a greater aptitude 
to conceive immediately after menstruation has ceased — this is 
the best time for intercourse; masturbation ; too frequent inter- 
course, and diseases of the rectum. 

Leucorrhcea, when alkaline or acid to excess, would cause 
sterility. 

Sexual frigidity cannot be regarded as causing barrenness, as 
the reverse is constantly seen in practice. General debility and 



STERILITY AND ANAPHROPISIA. 215 

anaemia, but especially the opposite, overfeeding and luxurious 
habits, are especially liable to interfere with conception. The 
fecundity of the human race is diminished by the life prevalent 
among the rich, and augmented by the habits and spare diet of 
the poor, in the proportion of six to one. To ascertain the cause 
of sterility, it is necessary to examine into the history and ante- 
cedents, the manner of menstruation, and the general bodily 
health. The care depends upon the removal of the cause, if this 
be possible. 

PROF. E. J. TILT, M. P., LONPON". 

Too much hair on the upper lip would lead to a suspicion of 
some defect of the ovaries. In sterility, occurring in too stout a 
person, fine her down by exercise, mental labor, and a diet from 
which bread, butter, milk, sugar, beef and potatoes are to a great 
extent excluded. The strong sympathy between the breast and 
the womb confirms the idea that by exciting the former the latter 
may be powerfully stimulated. Dr. Chas. Loupon states that 
four out of seven women were thus enabled to become mothers. 
Dr. Marshall Hall suggests the application of a strong infant 
to the breast, and Dr. Bayes advises the use of a breast pump, 
two or three times a day. If passion be too intense, it may 
cause barrenness ; and this has subsided and pregnancy followed 
after the prolonged use of cold hip-baths, cooling injections and 
camphor. Again, intercourse seems to act as a poison to the 
nervous system, causing unconsciousness, headache and utter 
prostration, even for days. In such cases the influence is lessened 
by previous attempts to induce orgasm. Temporary separation 
sometimes is useful, as giving to intercourse the stimulus of 
novelty. In Eastern countries, castor, ambergris, cantharides 
and aromatics are employed. When, consulted the physician 
should see to the health of both parties, employ tonics, keeping 
them apart, and let intercourse occur just after the menstrual flow. 

Dr. Thomas Epis mentions cases where sterility was removed 
by connection in the genu-pectoral position. 



216 DISEASES OF THE UTERUS AND ITS ANNEXES. 

PROF. DR. MAYRHOFER, OF VIENNA.* 



When a physician is consulted in reference to the sterility of 
a marriage, he should first satisfy himself whether the man or 
the woman is at fault. Contrary to the general opinion, in a 
large proportion of cases, about one-fourth of the whole, it lies 
with the male. It must be remembered that he may be capable 
of vigorous coition, and yet incapable of impregnating. (Azoo- 
spermia.) 

The second inquiry is whether the woman has ever been 
pregnant, whether her infertility is not the result of constant 
aborting. 

If this is the case, the chances of relieving her are better. But 
here again it is often the fault of the husband. It has been 
abundantly proven that men who have suffered from constitu- 
tional syphilis suffer such loss of vigor in the semen that their 
impregnations abort. 

The most common cause of an inability to conceive is found 
in previous existing inflammatory affections of the uterus. The 
case is favorable when on examination the vaginal portion is 
discovered to be conical in shape and with a contracted os. Here 
the operation recommended by Sims can be performed with a 
fair probability of restoring the fertility. 

Inflammatory processes complicated with flexions or versions 
also lead to sterility. The displacement is to be remedied, and 
this, if required, followed by discission of the os. 

One source of sterility may often be found in the sexual rela- 
tions. When these are quite frequent, there is not only less 
liability to conception but also greater to early abortion. The 
popular proverb "No grass grows on a well-trodden path" ap- 
plies here. Women of cold natures, averse to intercourse, bear 
more children than those of ardent passions. Prostitutes rarely 
conceive. The rare indulgence which some married couple 
practice in order to avoid too large a family actually favors child- 

*Handbuch der Fraucnkrankheiten, edited by Billroth, part II. 



STERILITY AND ANAPHR0DI8IA. 217 

bearing. Hence, when children are wished, strict moderation in 
coitus should be enjoined. 

Experiments prove that acid fluids are very destructive to the 
spermatozoids. Hence when the vaginal mucous discharge is 
acid, especially if it is also abundant, this may lead to infertility. 
The remedy here is to employ an alkaline lotion (one or two per 
cent, of caustic potash in distilled water,) just before coitus. 

Some women say that the ejaculation of the male immediately 
flows from the vagina. It is hardly possible that the whole of 
it can escape in this manner. But to such the old advice can be 
given that coition be conducted in the knee-elbow position. 

When on examination of the canal of the os it is found nar- 
row and closed with a plug of tenacious mucus, it is possible 
that this obstruction prevents the entrance of the sperm into the 
uterine cavity. A simple and harmless means of remedying this 
is for the woman to introduce jnto the vagina and against the 
os a sponge dampened with glycerine and retained by a string 
for withdrawing it. In a few hours this stimulates the uterine 
secretions and frees the canal of the cervix from obstructions. 

Discission and amputation of the os for sterility are by no 
means sure remedies; so far only a small percentage of success 
has followed their employment. Undoubtedly too much has 
been expected from them. It is better to precede them with 
cauterization of the os, a much simpler procedure, which alone 
is sometimes sufficient. 

That chronic cervical endometritis is a frequently overlooked 
cause of abortion and consequent sterility, has been pointed out 
by Dr. Arthur "W. Edis. (British Medical Journal, Xov. ; 
1878,) 

On examination per vaginum, the cervix may be found to be ap- 
parently healthy, no roughness nor any unusual condition exciting 
attention. In other instances the cervix is found to be more bulky 
than normal, the os puffy and patulous, the lining mucous mem- 
brane being granular. On passing a speculum, however, whether 
the cervix be normal in appearance or otherwise, we shall gen- 
erally find exuding from the os uteri a quantity of glairy tena- 



218 DISEASES OF THE UTERUS AND ITS ANNEXES. 

eious mucus, like unboiled white of egg, which is with consid- 
erable difficulty removed from the cervical canal. 

This condition not un'frequently ensues shortly after marriage, 
and sterility is an almost invariable result; but should concep- 
tion occur, abortion almost invariably ensues within the first few 
months, and, unless the patient be properly treated, much subse- 
quent uterine disturbance is sure to follow. 

Where the external os is naturally very small and circular, it 
may be necessary to divide it crucially, or even to slit up the 
cervix for half an inch or so, in order to prevent the tenacious 
discharge from accumulating in the cervical canal. 

His belief is that many cases of sterility, where the difficulty 
is overcome by free division of the cervix with the metrotome, 
are benefited as much by the depletion which ensues, and by 
the discharge being allowed free vent from the cervical canal, as 
by the division of any supposed stricture of the internal os 
uteri. 

Where the cervix is very bulky, the lips somewhat everted, 
and the canal very granular, nothing proves of so much service 
as local depletion by means of scarifying the surface or punctur- 
ing the cervix in several places, allowing an ounce or two of 
blood to flow, encouraging its continuance, if necessary, by warm 
water injections, and subsequently inserting tampons of cotton- 
wool saturated in glycerine, which tend to keep up a copious 
watery discharge and so lessen the bulk of the cervix. 

In cases where it is not deemed necessary to resort to division 
of the cervix or scarification, the insertion of a laminaria tent 
for twelve or twenty-four hours, so as to open up the cervix and 
expose thoroughly the inflamed mucous surface, and thus enable 
us to act freely upon it, may prove of much benefit. Care must, 
however, be taken that inflammatory mischief be not thereby 
set up. 



STERILITY AND ANAPHRODISIA. 219 

KESUME OF KEMEDIE3. 

Gradual Dilatation of the neck of the uterus by means of flex- 
ible bougies has incontestable good results in some 
cases. It apparently acts as a general excitant to the 
sexual system. 

Periods of Predilection. Dr. Cohnsteix, of Heidelberg, (Arch, 
fur Gynoekologie, Bd. xv., 1879,) has collected a num- 
ber of observations to show that generally sterile 
women are more likely to conceive at certain periods 
of the year than at others, and to cirry the embryo to 
maturity. These u periods of predilection," however, 
cannot be expressed in general terms, but must be de- 
cided for each individual case by independent observa- 
tion. 

Injections. Dr. De Sinety recommends lukewarm alkaline 
vaginal injections taken on going to bed. Vichy 
water may be used, or the following, which, he says, 
preserves for a very long time the activity of the sper- 
matozoids : 

181. R . Caustic potash, gr. iij.-v. 

Sugar, £ i. 

Water, f-<fvj. M. 
For vaginal injection. 

Alkalies. As above observed by Dr. Mayrhofer (page 216), 
the hyperacidity of the vaginal secretions may destroy 
the spermatozoa. This acidity may exist without any 
derangement of the health. Dr. A. Chanier states 
(Bull, de Therapeutique, June, 1880,) that the best rem- 
edy for this abnormal condition of the utero-vaginal 
secretions is the adoption of an alkaline regimen (alka- 
lies internally, alkaline baths, and tepid alkaline vagi- 
nal injections) ; that when the utero- vaginal secretions 
become neutral the obstacle to fecundation is removed, 
and conception will probably take place ; and that this 
disappearance of acidity under an alkaline treatment 
explains the success obtained in the treatment of ster- 
ility at the alkaline and sulpho-alkaline spas, as well 
as the renown of certain mineral springs. (Buben- 
quelle.) 

In order to change the acid secretions of the vagina, 
which destroy the spermatozoa, Dr. Chanier, of 



220 DISEASES OF THE UTERUS AND ITS ANNEXES. 

Paris, recommends alkalies, alkaline drinks and baths, 
such as of Vichy water, and alkaline vaginal injec- 
tions, as : 

182. R. Sodii sulphatis, gj: 

Aibuminis ovi, j. 

Aquae, Oj. M. 

For a vaginal injection. 

Bull. Gen. de Therapeutique, Nov. 12th, 1880. 



NYMPHOMANIA. 221 



NYMPHOMANIA. 

The form of genital erethism which is currently known under 
this name, is usually symptomatic of disease of the ovaries, of 
the uterus, or of vaginal or vulvar pruritus. In all cases, close 
study of its causative relations is demanded, with a view to their 
removal. In general treatment, the genetic sedatives mentioned 
below, especially the potassic bromide, should be exhibited in 
full doses. 

Occasionally the disease is distinctly of centric origin, depend- 
ing upon obscure cerebral or cerebellar disorganization, when it 
is to be considered as one of the symptoms of mania, and treated 
accordingly. 

In some rare cases (one mentioned in the Trans. Gyn. Soe. of 
Boston) it is marked and persistent, without any other defect 
either of the local or general health observable. In such in- 
stances, the treatment can only be tentative. 

BESUME OF KEMEDIES. 

Camphora and its monobromide have each considerable power as 
anaphrodisiacs, especially the latter, gr. iv., in capsules, 
three or four times a day. 

Cannabis Indica is a powerful sedative, with special influence on 
the uterus and its annexes, in relieving hypersethesia 
and reducing hyperemia. 

Conium. Dr. Alfred Meadows observes (Brit. Med. Jour., 
July, 1879,) that of all the anodynes we possess, none 
can compare with conium as an anodyne to the gene- 
rative or sexual organs. It calms vascular excitement 
and moderates ovulation itself. Gr. j. of the alkaloid 
conia may be used in a vaginal pessary nightly. 

Digitalis lessens the flow of blood to the generative organs, and 
in some cases acts very satisfactorily. 

Ether. Dr. Laurence Turnbull combines ether with cam- 
phor in abnormal sexual excitement 



222 DISEASES OF THE "UTERUS AND ITS ANNEXES. 

183. R. Vitelli ovi, f.|ij. 

Pulv. camphors, ^ij. 

JEtheris, f-Iij- M. 

Add the ether to the camphor, and then the emulsion. Dose, a 
tablespoonful every two hours. 

Ferri Bromidum acts moderately in sexual erethism, but less 

efficiently than the potassic bromide. 
Hyoscyamus. Tilt combines camphor with hyoscyamus. 

184. K- Camphorse, gr. ij. 

Ex. hyoscyami, gr. j. M. 

For one pill. Two or three, thrice daily. 

Lupulina has been found effectual as an anaphrodisiac, in doses 
of six to twelve grains several times a day. 

Potassii Bromidum is par excellence the sedative of the reproduc- 
tive system. Dr. Alfred Meadows believes that 
by its steady use we may limit ovulation, and indeed 
absolutely suspend the function altogether and pro- 
duce in time an atrophy of the ovary. (Brit. Med. 
Jour., July 12th, 1879.) The dose should be not 
less than 3 ss. three times daily. 

Stramonium, in small doses,' is said by Phillips {Materia 
Medico) to be very useful when this affection is uncon- 
nected with disease of the sexual organs, and where 
there is no considerable depression of the mind. 

Zinci Bromidum is given by Charcot as an anaphrodisiac in 
doses of gr. v.-xx., daily. 

Clitoridectomy, as practiced by the late Mr. I. Baker Brown, 
of London, is justifiable where other means fail, and 
the cause appears to be local irritation. 



CHAPTER III. 



DISEASES OF THE VAGINA, URETHRA, AND 
BLADDER. 

Synopsis of Diagnostic Points — Vaginitis, Acute and Chronic, 
Non-specific — Vaginitis, Specific, Gonorrheal — Vaginismus 
and Dyspareunia — Vaginal Growths — Pruritus Vulvoe and 
Vulvitis — Cystitis, Acute and Chronic — Urethritis — Urinary 
Disorders — Irritable Bladder, Dysuria, Polyuria, Ischuria, 
Enuresis, Vesical Tenesmus, etc. 

SYNOPSIS OF DIAGNOSTIC POINTS. 

VAGINITIS. 

In the various forms of vaginitis, the chief difficulty in diag- 
nosis is to distinguish gonorrhoea! from simple inflammations. 
Dr. N. L. Galabin, however, asserts (Diseases of Women, 
1879,) that a conclusion based upon the following signs, or the 
majority of them, will be right in ninty-nine cases out of a 
hundred. 

Gonorrhoeal vaginitis is characterized by : 

1. Its sudden onset. 

2. The markedly yellow or greenish color, offensive smell, and 
irritating quality, of the discharge. 

3. The smarting on micturition produced by extension of the 
inflammation to the urethra. 

4. The occurrence of inflammation or abscess in the vulvo- 
vaginal glands, the ducts of which can often be distinguished as 
injected points just in front of the hymen or its remnant. 

5. Marked oedema of the vulva and buboes. 

223 



224 DISEASES OF VAGIXA, URETHRA, AXD BLADDER. 

6. The communication of contagion to the male 

When most of these are present, the case is almost, but not 
entirely, certain to be one of specific infection. 

Dr. Lombe Atthill says, speaking of the two forms of vagi- 
nitis : " I must avow that I know of no means of distinguishing 
with any certainty between the two." (Diseases Peculiar to 
Women, p. 37.) 

An almost pathognomonic sign of gonorrhceal vaginitis, 
according to Mr. Tait, is cedema of the vulva. All cases of 
specific origin do not present it; but where it is present, it may 
be considered the strongest proof of infection ; and where this is 
combined with a high degree of pain and scalding, especially 
during micturition, the case may be considered as beyond doubt 
of infectious origin. The discharge in such cases is profuse, pur- 
ulent, and not glutinous, and the mucous surface of the vagina is 
of a yellowish-red color ; whereas in non-specific or catarrhal 
vaginitis, the discharge is scanty and tenacious, and the mucous 
surfaces of a purple hue. 

Dr. L. De Sixety gives another diagnostic point which he 
considers next to pathognomonic. It is based on the fact that 
urethritis in the 'female, of other than gonorrhceal origin, is 
almost unknown; its presence, therefore, is nearly a proof of 
blenorrhceal poison ; but it must be determined by a peculiar 
procedure. Having carefully cleaned the vulva and vestibule, 
the finger introduced into the vagina and pressed upon its ante- 
rior wall, is to be withdrawn, continuing the pressure from below 
upward, and from behind forward. Repeating this two or three 
times if necessary, the liquid in the urethra will be brought to 
the orifice and can be examined. 

This measure should be employed some time after micturition. 
If pus is discovered, the urethritis, and with it the gonorrhoea, is 
demonstrated. The only possible error would be a urethral 
chancre ; but this would certainly be felt by the finger used as 
directed. (Traite de Gynecologies, 1880.) 



SYNOPSIS OF DIAGNOSTIC POINTS. 225 

CYSTITIS. 

The principal local signs of inflammation of the bladder are 
pain, tenesmus, and frequent desire to urinate, followed by strain- 
ing as if the organ had not been fully emptied. The pain is 
usually a dull ache in the perinseum and the sacrum. Frequently 
the color and odor of the urine are little changed; mucous sedi- 
ment is usually present. 

The frequent urination differs from that seen in pregnancy and 
prolapsus by not diminishing when the recumbent position is 
assumed. The presence of tenesmus differentiates it from that 
witnessed in abdominal tumors, pelvic peritonitis, and inflamma- 
tions of the urethra. Palpitation and percussion of the abdomen 
will develop tenderness of the bladder, if it exists. The catheter 
or sound will distinguish cystitis from the pressure of stone or 
other foreign body in the bladder. And the endoscope affords 
a means of ascertaining the exact appearance of the interior of 
the bladder and urethra. 

Dr. E. J. Tilt observes : " What one man calls chronic cysti- 
tis, another calls irritable bladder," so closely, in many instances, 
do these conditions shade into each other. 

URINARY DISORDERS. 

The functional disorders of the bladder are divided into the 
following forms : 

1. Polyuria — frequent urination and in considerable quantity. 

2. Ischuria — difficult urination and imperfect emptying of the 
bladder. 

3. Dysuria — painful urination. 

4. Enuresis — incontinence of urine. 

5. Vesical tenesmus — spasmodic pain after urination is com^ 
pleted. 

6. Vesical Irritability — frequent and painful micturition, with 
the passage of very little urine. 

15 



226 DISEASES OP VAGESA, URETHRA, AND BLADDER. 



VAGINITIS, ACUTE AND CHRONIC -VAGINAL 
CATARRH-LEUCORRHCEA-COLPITIS. 

Of the general means at our disposal to combat vaginal affec- 
tions, the following survey is given by 

DR. A. LEBLOXD, OF PARIS.* 

Vaginal Injections. This writer observes that the tempera- 
ture of vaginal inject! ous has much to do with their effects. 
Taken cold, they produce an afflux of blood to the pelvic basin, 
and are thus stimulant ; while taken warm, their action is sedative. 
The dangers which some writers have referred to as attending 
vaginal injections are probably owing to the fluid being thrown 
into the uterus ; this can largely be avoided by using a syringe 
the apertures at the end of which are on the sides, and not at 
the extremity of the nozzle. When there is much inflammatory 
action in and near the vagina, the fluid should be thrown in very 
gradually, as long as ten or fifteen minutes being consumed in an 
injection. In such inflammatory conditions, injections of infu- 
sions and solutions of hyoscyamus, belladonna, etc., are often 
employed with advantage; these should always be administered 
lukewarm, as cold applications in such conditions may lead to 
injurious reactions. 

Vaginal Irrigations. These may be either of liquids, as water, 
plain or medicated; or of fgases, as carbonic acid gas or the 
vapors of chloroform, ether, etc. A variety of apparatus has 
been employed at various times, which need not be here de- 
scribed. Whichever one is used, the irrigation should continue 
at least half an hour at a time to be efficacious. 

In uterine neuralgia and dysmenorrhea, advantage has been 

' derived from injection of chloroform vapor into the vagina and 

uterus. This may be done by the apparatus devised by Scan- 

* Trait& de Chirurgie Gynecologique, Paris, 1879. 



227 

zoxi, or by means of a bottle with a large cork, into which two 
tubes are introduced, the one connected with a vaginal cannula, 
the other with a hand-ball for forcing air. The chloroform is 
poured on some cotton in the bottom of the bottle, the cork in- 
serted, the cannula introduced into the vagina, and the vapor 
driven in by pressing the ball. The injection of chloroform 
vapor sometimes produces considerable irritation of the vaginal 
walls, and it therefore must be used with caution, and not of 
much strength. 

Medicated Tampons. These are valuable in many forms of 
vaginitis. They should be long, so as to separate the vaginal 
walls throughout their whole extent, and made of dry wadding. 
They are medicated with glycerine, the glyceroles, alum, tannin, 
saponified coal tar (which has been highly extolled by M. SiRE- 
dey,) or other substance. 

The proper introduction of the tampons can only be done with 
a speculum. Their extraction will be facilitated by annointing 
them with cerate or oil. They should not be allowed to remain 
in for many hours at a time, lest they interfere with urination. 
In extracting them, patience and care, and the free use of warm 
water, are often necessary to avoid painful dragging, or lacera- 
tion of the delicate lining membrane of the vagina. 

Vaginal Cataplasms. At one time this method of medication 
was much employed, but of late years has fallen out of use. The 
neatest and most effectual are prepared from wadding soaked in 
infusion of fucus crispus. It is to be had ready prepared from 
pharmacists, in the form of sheets. A piece about three inches 
square is cut off, moistened with warm water, rolled into the form 
of a cylinder, and a string being attached to facilitate its with- 
drawal it is inserted into the vagina by the hand or a porte- 
tampon. To be efficacious, they should be renewed daily, and 
without interruption for considerable time. They have been 
found valuable in many inflammatory affections of the vagina 
and os. 

Vaginal Suppositories, or Medicated Pessaries. These have 
been familiar to the profession from the earliest antiquity. The 



228 DISEASES OF VAGINA, URETHRA, AND BLADDER. 

excipient may be cerate, cocoa-butter, or petroleum products con- 
taining sufficient paraffine to give consistency : the active ingredi- 
ent is belladonna, morphia, iodide of lead, etc. The most 
appropriate size is an inch and a half in length, and three- 
fourths of an inch in circumference. They can be introduced 
daily by the patient herself. As the absorptive power of the 
vaginal mucous membrane is very slight,* they are less efficacious 
than rectal suppositories. 

LOMBE ATTHILL, M. D., OF DUBLIN. 

In subacute vaginitis, this author states that a mode of treat- 
ment of the greatest value is by the application of glycerine. With 
this a roll of cotton- wadding, with a strong thread attached, is 
saturated, introduced into the vagina through a speculum, and 
left for twenty-four hours. The glycerine, by its affinity for 
water, produces a copious, serous discharge, which in a marked 
degree relieves the congestion that exists. 

Dr. Atthill does not employ either alum or sulphate of zinc 
in vaginal injections where any inflammation is present. They 
both coagulate the albumen in the discharge, and cause much 
discomfort. Borax is better, as 

185. R . Sodii biboratis, % j. 

Aquse, Oj. M. 

In some cases, much benefit will be derive-d from adding tobacco, 
gr. xv.-xxx., to this amount; or when the patient is nauseated 
by the tobacco, one ounce of hops may be substituted. 

Where there is no vaginal irritation, but only a profuse and 
weakening leucorrhoeal discharge, astringents, such as alum or 
sulphate of zinc, 3j. to water Oj., will often prove very useful. 
So also will decoction of oak bark, although this has the objec- 
tion of staining the linen. 

*Dr. Hamburger, however, and some other writers have maintained that 
the absorptive power of the vaginal surface is considerable. The general 
assumption is that it is one-half that of the rectum. # As the fact rests uncer- 
tain, caution should be exercised in using the more potent drugs. 



229 



T. FIXCH, M. D., OF ILLINOIS. 



1S6. R. Potassii chloratis, %iv. 

Potassii pernianganatis, gr. x. 

Aquae, Oj. M. 

Inject a teacupful morning and evening, in acute vaginitis. Warm sitz- 
baths and saline laxatives are important accessories. (Chicago Medical Exami- 
ner, December, 1874.) 

DR. EDIS, OF MIDDLESEX HOSPITAL, LONDON. 

Iu the subacute form of vaginitis this writer recommends 
swabbing the vagina freely with strong carbolic acid. A specu- 
lum is inserted, and the fundus vaginaB first touched ; the 
speculum being gradually withdrawn, the acid is allowed to 
come into contact with the whole length of the vagina, stopping 
short just before the junction of the mucous membrane with the 
vulval outlet, otherwise intense burning pain will be produced. 
Care must be taken not to allow any excess of the acid to run 
down externally. It is well to insert a pledget of cotton-wool 
soaked in oil just within the orifice of the vagina, to prevent this ; 
but should much burning pain ensue, the patient is directed to 
squeeze a little olive oil into the passage, and to insert a morphia 
suppository per anum. In several instances, this method of 
treatment has been adopted with marked success ; two or three 
applications, at most, arresting the discharge, after several weeks' 
ineffectual treatment with ordinary lotions. 

PROF. SCANZONI. 

This author recommends, in vaginitis, the employment of a 
tampon rolled in powdered alum. If the sensibility be too acute, 
the alum is to be mixed with two parts of sugar. The tampon 
should not remain in the vagina longer than twelve hours, and 
ought to be introduced every two or three days. When it is 
withdrawn, the vagina should be cleansed by warm water injec- 
tions, and a bath taken. Some physicians replace the alum 
tampon by a sachet of gauze filled with an astringent powder, 
such as oak bark. 



230 DISEASES OF VAGINA, URETHRA, AND BLADDER. 
SIR CHARLES CLARKE, OF LONDON. 

This distinguished physician often prescribes the following 
internally in protracted leucorrhceal discharges. It is also highly 
praised by Dr. S. Ashttell in his work on Diseases of Women : 

187. R. Infusi cascarillae, £,lj- 

Aquae pimeotae, f. t ^ss. 

Tinct. sabinae comp., f.g i.-ij. 

Syr. zingiberis, f. ^ j. M. 

For one dose three times daily ; a blister to the sacrum. 

* DR. BUYS, OF BORDEAUX. 

This author (Bordeaux Medical, 1873,) recommends in chronic 
discharges from the vagina the following injection : 

188. R . Tincturae iodinii, gtt. xiv. 

Acidi carbolici, gtt. vi. 

Glycerinae, f-.?j- 

Aquas destillatse, f.^ vj. M. 

For a vaginal injection. 

PROF. TRELAT, PARIS. 

The following has been extolled by Professor Trelat, in 
vaginal leucorrhcea : 

189. R • Acidi carbolici pur., gr. xv. 

Aquae coloniensis, %}. 

Aquae, % ij. M. 

With this he moistens a tampon, and carries it to the bottom 
of the vagina. After the surfaces have been cleaned by the use 
of this, he substitutes for it a milder preparation, as 

190. R . Acidi tannici, % j. 

Glycerinae f-.lj- M. 

To be applied on a tampon. 

DR. A. A. BOINET, PARIS. 

191. R. Tincturae iodinii, f.^ iij. 

Acidi tannici, gj. 

Potassii iodidi, 3 ss. M. 



VAGINITIS, ACUTE AND CHRONIC. 231 

This solution is employed to paint the vagina, in acute or 
chronic vaginitis, and the uterine neck, in engorgement and 
ulceration. The proportion of the tincture of iodine is to be 
lessened, according to the character of the inflamed tissues and 
the effect that it is desired to produce. 

J. N. DEMARQUAY, M. D., PARIS. 

192. B . Acidi tannici, gr. xv.-xxx. 

Glycerinse, f. 3 ijss. M. 

Tampons of wadding immersed in this solution are introduced into the 
vagina after the acute symptoms have been relieved by baths, emollient injec- 
tions and repose. 

M. MAISSONNEUVE, PARIS. 

193. R. Ferri sulphatis, 2>ij ss - 

Aquae, Oj. M. 

This solution is advised in injections in vaginitis. After each 
injection, a certain quantity of starch is to be introduced into 
the vagina. 

EDMOND LANGLEBERT M. D., PARIS. 

194. R. Tincturse iodinii, f. gv.-x. 

Aqua? distillate, Qijv 

Potassii iodidi, q. s. to prevent the 

precipitation of the iodine. M. 

A useful injection in vaginitis after the acute stage has passed. 
Ulceration, if any exist, should be lightly touched with nitrate 
of silver. If the vaginal discharge be offensive, the following 
injection is useful : 

195. R. Liquoris sodse chlorinatae, f-^ v J« 

Aquae destillatse, O iss. M. 

E. J. TILT, M. D., OF LONDON. 

This author states that whether vaginitis occurs spontaneously 
or as the result of uterine catarrh, it is best cured by the injec- 
tion of a solution of nitrate of silver. His usual solution is one 
of forty grains to the ounce, and he directs that the patient be 
placed on her back, a small glass speculum introduced as far as 



232 DISEASES OF VAGINA, URETHRA, AND BLADDER. 

possible, and an ordinary glass syringeful of the solution be 
injected. The speculum is then to be very gradually withdrawn 
to the vicinity of the vulva, after the fluid has been left in con- 
tact for two or three minutes; then the speculum is to be 
removed, and the'fluid received into a small cup. Or, a specu- 
lum may be applied, and as it is withdrawn, the sides of the 
vagina are freely touched with the toughened stick of silver 
nitrate, after the plan of Ricord in granular vaginitis. 

These measures recommended by Dr. Tilt seem unnecessarily 
severe. Dr. A. Courty [Maladies de V Uterus et de ses Annexes, 
1866,) advises to begin with a solution of gr. xv. to water f. Ij. : 
although he adds that it may be increased to gr. xxiv. or even 
to gr. xlviij. He insists, especially, that the vagina shall be 
carefully washed and wiped with cotton through the speculum 
before the caustic solution is applied. 

DR. GUIPON, PARIS. 

196. R. Ferri sulphatis, gij. 

Ferri subcarbonatis, ^ iij. 

Cinchona? pulveris, 

Cane 11a? pulveris, 

Ergotinse, aa ,^j. M. 

One or two pinches to be administered before the two principal meals, in 
idiopathic leucorrhcea. Its usage is to be suspended on the approach of the 
menstrual epochs. Prolonged vaginal injections morning and evening, with 
cold water and vinegar. Tonic regimen. 

197. R • Acidi tannici, gr. ix. 

Cerae albae, sjvj. 

Adipis, 3 iv. M. 

Melt by a slow heat, and cool in a mould. 

This is a useful vaginal suppository in leucorrhsea. 

LAWSOX TAIT, F. R. C. S., BIRMINGHAM. 

This author warns against the use of vaginal injections in 
acute vaginitis, on account of the risk of causing endometritis 
and ovaritis. He considers no remedy equals the steady appli- 
cation of hot fomentations of acetate of lead and opium, the 



233 

same drugs being inserted into the vagina in the form of soluble 
pessaries. When the acute stage has passed, pessaries of cocoa- 
butter containing tannin or acetate of lead are useful ; after that, 
injections of a four per cent, solution of permanganate of lime will 
establish a cure. 

In chronic forms, which do not extend to the uterus, brush- 
ing the whole surface with equal parts of glycerine and carbolic 
acid, followed by the use of an astringent pessary of acetate of 
lead or sulphate of zinc, will speedily effect a cure. 

Dr. Xeftel, of New York, has called attention to several 
cases of intense vaginitis, coincident with lead-poisoning from 
the use of cosmetics, and which disappeared under the internal 
use of iodide of potassium and sulphur, without local medication 
of any kind. 

DK. L. DE SINETY. 

Acute Vaginitis. At the outset the treatment will consist in 
lotions and lukewarm emollient injections. As soon as the va- 
gina permits it, small tampons charged with a weak solution of 
carbolic acid (1 to 300) should be introduced and retained. Later 
this may be followed by painting the interior coat with a solu- 
tion of silver nitrate (1 to 30.) To succeed with this, every part 
of the interior of the vagina must be touched ; and this re- 
peated every three or four days. 

Chronic Vaginitis. Astringents have the preference in this 
form. The best, in order of excellence, are tannin, alum, and 
sulphate of zinc- Tampons wet with one of the following solu- 
tions, and frequently renewed, should be employed : 

198. R. Acidi carbolici crystal., gr. x. 

Alcoholis, q. s. to dissolve. 

Add: 

Acidi tannici, 3 j. 

Glycerinae, ^j. M. 



Or 



199 R. Acidi carbolic!, gr. vijss. 

Alcoholis, gji> 

Acidi tannici, 3ij ss - 

Aquee, f. 5 iij— M. 



234 DISEASES OF THE VAGINA, URETHRA, AND BLADDER. 

These tampons act better in vaginal leucorrhoea than injections. 
They may profitably be alternated with alkaline vaginal enema- 
ta. A general tonic treatment is often required to aid these local 
measures. 

PROF. J. QUISAC, OF MOKTPELLIER. * 

This writer defends the opinion that chronic leucorrhoea is 
essentially of two varieties, The first, or active, form depends 
etiologically on a constitutional cachexia, as the scrofulous, rheu- 
matical or gouty. While it is often possible, in these cases, to 
check the flow by persistent medication with stimulants and 
astringents locally, our author believes that it is bad treatment 
to do so, the constitutional taint being almost sure to re-appear 
in some graver form. He looks upon the leucorrhoea in such 
cases as a sort of emunctory to the system, which should not be 
directly interfered with. Treatment should be constitutional, 
and directed toward the cachexia, with the disappearance of 
which the leucorrhoea will spontaneously subside. 

The second, ov passive, form is nearly always the result of an 
anseinic or chlorotic condition of the blood, or of an enfeebled 
constitution in women of lymphatic temperament. The indica- 
tion here is primarily for ferruginous preparations, a liberal diet, 
and favorable hygiene. Local treatment is of much less mo- 
ment. 

In fact, the common plan of vaginal injections of astringents, 
etc., can only claim a prominent position in the treatment of this 
malady when the cause is distinctly local, as inflammations of 
the os, irritations from foreign bodies, etc. 

DR. DESPReS, OF PARIS. 

The inconvenience, if not absolute danger attending the plug 
d demeure in certain vaginal and uterine affections, has often 

* Therapeutique Medicate, Paris, 1879. 



VAGINITIS, ACUTE AND CHRONIC. 235 

been dwelt upon by many surgeons of note, but according to M. 
Despres, these inconveniences have been singularly exaggerated, 
at least when the plug is judiciously used. Against the most 
frequent affections of the vagina and vaginal portion of the ute- 
rus, M. Despres has recourse to a very simple means of cure. 
The agent he employs is a medicated plug called tampon de 
Lourcine. The employment of this tampon can be traced back 
to the foundation of this hospital, but, like many other excellent 
remedies, was abandoned. The principle to which it owes its 
virtue is sulphate of alum. This substance is buried in a piece of 
cotton wadding about the size of a walnut, and covered by a bit 
of fine linen. The plug thus formed is armed with a string to 
draw it out when desired. The quantity of alum used is two 
grammes. Vaginitis of the gravest type is cured in five or six 
weeks by the application of this plug. In ulceration of the va- 
ginal cervix and os, caustics should never be used, which, ac- 
cording to Dr. Despres, only tend to aggravate the wound. 
The ping, on the contrary, succeeds admirably, presenting a 
double mode of action. It is endowed with astringent properties 
resulting from the dissolving of the alum in the utero-vaginal 
liquids. It acts also by compression, especially if care be taken 
to put it in the posterior cul de sac of the vagina. It suffices to 
apply one plug a week, and it should not be left in longer than 
twenty-four hours, after which all the alum is dissolved, and the 
plug becomes a foreign body, which should be withdrawn. The 
withdrawal effected, the local treatment is limited to the injection 
three or four times a day of water, as warm as the patient can 
support. 

HENRY M. FIELD, M. D., OF BOSTON. 

Atony of the vaginal walls. This condition is quite common, 
accompanied or not by a leucorrhceal discharge. Frequently 
this may be relieved by stringent vaginal suppositories, as, 

200. R. Acidi tnnnici, gr. x. 

Butyri cocose, q. s. M. 

For one suppository. One daily. 



236 DISEASES OF VAGINA, URETHRA, AND BLADDER. 

For this, borax or alum may be substituted. The borax is a 
mild astringent and local tonic. The extract of rhatany may 
also be used with excellent results, [Jour. Gyn. 8oc, Boston, 
vol. VI.) 

KESUME OF EEMEDIE'S. 

INTERNAL REMEDIES. 

Alumen, in doses of gr.-v. viij. thrice daily, in combination with 
pilulae aloes or with nitre (gr. x.,) is productive of good 
in some obstinate cases of leucorrhcea. 

Alkalies are often of value in correcting acrid discharges from 
the vaginal membranes. 

Cantharides. The use of the tincture, once so highly praised by 
Dr. Dewees and others, has fallen into comparative 
disuse. It was given gtt. xx. thrice daily, in a de- 
mulcent draught, the dose being subsequently increased 
to gtt. xl-L, until it produced slight strangury, when it 
was diminished or the medicine discontinued. The 
average period of cure was about four months. 

* Copaiba is highly spoken of by a number of writers, in doses 
of TTL x v. thrice daily. 

Cubebs have been employed with success. 

Ergot, in doses of gr. v. thrice daily, often gives good results, 
especially if a blister be applied to the sacrum. 

Gallo3 Pulvis, in doses of gr. x.-xx., in decoction of tormentilla, 
daily, is given with great benefit at the Lock Hos- 
pital, London. 

Hcematoxyli Lignum, in decoction, has been employed with ad- 
vantage. 

Juniperus frequently exerts a beneficial influence. 

Krameria. The extract, in doses of gr. xx. daily, often arrests 
the discharge and improves the tone of the system. 

Potassii Nitras. Dr. Dewees prescribed the following with 
success in some obstinate cases : 

201. R . Potassii nitratis, £ v. 

Aluminis, 3 ijss. M. 

Divide into thirty powders ; one thrice daily. 

Pulsatilla, tincture, gtt. v. thrice daily, is said by Phillips 
quickly to relieve leucorrhcea attended by pain in the 



VAGINITIS, ACUTE AND CHRONIC. 237 

loins, depression and derangement of the nervous sys- 
tem. 

Sabina has been recommended. Its use is most promising in 
obstinate leucorrhceal discharges. 

Tannicum Acidum, in doses of gr. ij.-iij. twice or thrice daily, in 
aqueous solution, combined with a small portion of 
dilute nitric acid, has been found an efficacious remedy. 

Terebinthince Oleum is recommended, in small and repeated doses, 
by Dr. Pereira, in chronic cases, unattended by in- 
flammatory symptoms. 

VAGINAL INJECTIONS. 

Acetum, 3 ij. to a quart of water, is a popular and often useful 

domestic remedy. 
Acidum SalicyUcum. Injections of sylicylic acid have been used 

with perfect satisfaction iu all discharges from the 

vagina. This formula is offered : 

202. R. Acid, salicylic, giss. 

Glycerina?, f. 3 iij. 

Aquae, O ij. 

SiG. — For six injections. One daily. M. 

In uterine catarrh the canal should be injected by 
means of a catheter small enough for the purpose. The 
acid should be well dissolved in the liquid, for obvious 
reasons. This method is highly recommended in the 
treatment of chronic blennorrhagia, and it is said to 
succeed perfectly. 

Aloes. French writers have lauded in chronic and obstinate 
vaginitis, especially of blennorrhoeal origin, injections 
medicated with tincture of aloes. (Fonnsagrives, The- 
7-apeutlque Appliquee, vol. II.) 

Alumen. Dr. Tyler Smith, of London, has found the follow- 
ing injection very serviceable : 

203. R. Alnmnis, ^ ss. _ 

Acidi tannici, £> j~ij- 

Aquae, Oij. M. 

One-half to be used at night, and the other half in the morning. 

Oak bark decoction also makes a good vehicle : 

204. R. Aluminis, S.j. 

Decocti quercus albse, Oj. M. 



238 DISEASES OF VAGINA, URETHRA AND BLADDER. 

Dr. E. J. Tilt, of Loudon, remarks that he has re- 
peatedly known the prolonged use of alum injections 
produce an irritable, sub-inflammatory state of the 
cervix uteri; he advises, therefore, when astringent 
injections are long continued, to use those of alum, zinc 
and sugar of lead, on alternate days. Leblond notes 
that it hastens the exfoliation of the vaginal epithelium, 
and curdles the albumen in the discharges, and is ob- 
jectionable on these accounts. Dr. Atthill never 
uses it when any inflammatory action is present. 
Ammonii Murias has occasionally been used in vaginal injection : 

205. R • Ammonii muriatis. % j.-iv. 

Aquae, Oj. M. 

Argenti Nitras, in solution, has been advised as a vaginal injec- 
tion : 

206. R. Argenti nitratis, gr. iij. 

Aqnse distillate, f-^ij- M. 

This agent, once very popular, is now much less so. 
Atthill remarks that better results can almost always 
be obtained by other means, and this is the general 
opinion. Dr. Sinety, however, still recommends 
paint \ng the whole of the vaginal wall with a solution 
of 1 to 30. 

*Bismuthi Subnitras, applied once a day in powder, on a small 
piece of charpie, by means of a speculum, to the whole 
of the vaginal mucous membrane, is an effectual rem- 
edy in some cases. Or it may be mixed into a thick 
cream with glycerine, and applied to the whole of the 
vaginal membrane. 

Boracicum Acidum. Dr. Warren Greene, of Maine, has em- 
ployed with marked benefit in acute vaginitis, a glyce- 
role ojboratio acid. (Boston Med. and Surg. Jour., 1880.) 
Hot glycerine dissolves 3 iij. to the ounce, and holds it 
perfectly on cooling. As a lotion, it may be used 3 ij. 
to water Oj. 

Ccdcis Aqua. The vaginal injection of a weak solution of lime- 
water sometimes effects a cure after the failure of other 
remedies. 

Catechu. The infusion, injected once or twice a day, often greatly 
lessens the discharge. 



VAGINITIS, ACUTE AND CHRONIC. 239 

Cocculus Indlcus is recommended by Phillips, when the dis- 
charge is of a sero-purulent character, with pain in the 
lumbar region. Gtt. v.-x. of the tincture, two or three 
times a day. 

Cupri Sulphas. The following injection, given after previously 
washing out the vagina with soap and water, is of ser- 
vice : 

207. R . Cupri sulphatis, gr. xx.-xxx. 

Aquse tepidse. Oss. M. 

To be used thrice daily. 

Fecuhun. Dr. George H. Bixby, of Boston, has recommended 
starch injections in vaginal inflammation. (Jour. Gyn. 
Soc, Boston, vol. V.) His formula is : 

208. R . Thin boiled starch, | pint. 

Pulv. chlorate of potash, 1 teaspoonful. 

Glycerine, 4 *' M. 

Use, by injection, every night, or twice daily. 

Ferri Chloridi Tindura, 3 j. to a pint of water, forms an excel- 
lent astringent injection. 

Glycerina, as dilute solution, as an addition to other medica- 
ments, exerts an excellent effect. It increases the dis- 
charge, but relieves congestion. 

Granati Hadicis Cortex. The decoction of the root-bark (f ij., 
aquse Oij., boiled to Oj.) is a useful vaginal injection, 
combined with alum : 

209. R. Aluminis, £j. 

Decocti granati radicis corticis, Oj. M. 

Hydrargyri Chloridum Corroslvum. Dr. Dewees employed the 
following solution as a vaginal injection in obstinate 
leucorrhseas : 

210. R. Hydrargyri chloridi corrosivi, gr.j. 

Aqua>, f.-fij. M. 

It should be used with great caution, as, even at this strength, 
it may act most painfully on the surface. Milder means are 
safer. His directions are that it is to be used only in chronic 
cases; given at first only once a day, then several times a day, 
until heat and irritation occur, when lotions of acetate of lead 
will effect the cure. 



240 DISEASES OF VAGINA, URETHRA AND BLADDER. 

Iodihium. Dr. Tilt gives : 

211. R. Tinct. iodinii, 

Tinct. opii, aa f-^ij- M. 

Two or three teaspoonfuls to be added to a pint of water, to be 
used once or twice a day. 

Iodoform. Tampons smeared with iodoform are often valuable 
in inflammatory affections of the vagina. Oil of fen- 
nel or Peruvian balsam will help to mask the odor. 
In leucorrhoea 3 j. of iodoform to § j. of tannic acid may 
be applied in a dry state. (Bartholow.) 

Matico. The infusion has been injected with benefit. 

Plumbi Acetas. The following is a useful vaginal injection : 

212. R. Plumbi acetatis; g r -vj. 

Aquas, f.^j. M. 

Plumbi Subaeetas is preferred by Dr. Tanner in the following 
solution, the whole of which is to be used twice a day : 

213. R. Liquoris plumbi subacetatis, f-.^ij- 

Aquae, Oj. M. 

Potassii Chloras. The following vaginal injection has been em- 
ployed with success : 

214. R. Potassii chl or atis, £j. 

Aquae distillatae, f. J viij. M. 

Potassii Permanganas, in dilute solution (gr. v. to aquae f. |j.) is 
undoubtedly very beneficial in many cases, especially 
where the discharge is foetid. An objection to it is that 
it stains the linen. 

Pulsatilla. 3j. of the tincture to Oj. of water, is recommended 
by Phillips for a daily enema in obstinate leucorrhoeas. 

Quercus Alba. The decoction, with or without alum, is a safe 
and effective vaginal injection. 

Quinice Sulphas, in solution, gr. x-xxx. to aquse § j., is often a 
very efficient application in acute cases. 

Sodii Boras. Dr. Graily Hewitt, of London, advises, when 
the discharge is acrid, frequent ablutions of the exter- 
nal parts with a borax lotion, to prevent irritation. 
Atthill believes that it is both astringent and tonic. 
The usual strength is 3 j. to water Oj. 



241 

Sodii Carbonas. Dr. S. Ashwell sta'es that repeated experi- 
ments have shown that inflammation of mucous mem- 
branes always engenders a free acid on their surface, 
and that to neutralize this he and others have obtained 
almost immediate relief by the use of an alkali. {Dis- 
eases of Women, p. 157.) He recommends: 

215. R. Sodii carbonas, BJ-~"SJ- 

Aquae, Oj. M. 

For a vaginal injection in leucorrhoea. 

Tannin. This is one of the most popular substances for astrin- 
gent injections. The amount required is 3 ss.-j. in a 
pint of cold water. Glycerine may be added. 

TJiea. An infusion of green tea makes a good injection. 

Tormentilla. The decoction ( 3 ij. aquas O is«, boiled to Oj.) 
is an excellent vehicle for alum, in vaginal injection. 

*Zinci Acetas. This salt forms a useful vaginal injection, in the 
strength of gr. ij.-iv. to aquas f. §j. The following 
was a favorite formula with Sir Astley Cooper : 

216. R. Zinci sulphatis, gr. vj. 

Liquoris plumbi subacetatis. ttlxxx. 

Aqua;, f-^iv. M. 

By this formula decomposition takes place, the acetate 
of zinc resulting. 
Zinci Oxidum. The following vaginal injection has been given 
with success : 

217. R. Zinci oxidi, 5 ss. 

Aqua?, Oij. M. 

Zinci Sulphas, gr. j. to water f. §j., is beneficial where the inflam- 
mation is slight. 

Zinci Sulpho-Carbolas, gr. v. to aquas §j., as an injection, is said 
by J. Matthews Duncan to be an excellent remedy 
in the chronic forms; each injection should be of 
about ten ounces. 

OTHER LOCAL MEASURES. 

Poultices. M. Fournier, of the Lourcine Hospital, Paris, 
makes use. of voluminous cataplasms which quite dis- 
16 



242 DISEASES OF VAGINA, URETHRA AND BLADDER. 

tend the vagina ; and he states that he was first induced 
to resort to this practice by having observed the effects 
which had several times resulted from his pupils having 
forgotten to remove large wadding plugs that had been 
introduced, in each instance, these, so far from having 
acted prejudicially, had proved of service in treating 



vaginal tampons. (See page .) 

Cotton. This is a convenient substance for introducing local 
medication into the vagina. Any of the ordinary 
medicated cotton can be used. 

Marine Lint has been extolled by Dr. A. J. C. Skene as one of 
the most excellent materials for a tampon in vaginitis. 
The tar which it contains acts antiseptically, and is 
also a very efficient agent in inflammations of mucous 
membranes generally. 

Hot-water Vaginal Douche. — This not unfrequently fails to effect 
good results owing to ignorance or negligence in the 
details of applying it. The following rules are laid 
down by Dr. E. C. Dudley, of Chicago, for its admin- 
istration. {Chicago Medical Gazette, 1880): 

1. It should invariably be given with the patient 
lying on the back, with the shoulders low, the knees 
drawn up and the hips elevated on a bed-pan, so that . 
the outlet of the vagina may be above every part of it. 
Then the vagina will be kept continually overflowing 
while the douche is being given. 

2. It should be given at least twice every day, morn- 
ing and evening, and generally the length of each ap- 
plication should not be less than twenty minutes. ■ 

3. The temperature should be as high as the patient 
can endure without distress. It may be increased from 
day to day, from 100° or 105° to 115° or 120° Fahr. 

4. Its use, in the majority of cases, should be con- 
tinued for months, at least, and sometimes for two or 
three years. Perseverance is of prime importance. 

The sitting posture is especially objectionable, for 
another reason. It favors pelvic congestion by force 
of gravity, while the dorsal position utilizes this force 
during the application of the douche. 



VAGINITIS, ACUTE AND CHRONIC. 243 

A satisfactory substitute for the bed-pan may be made 
as follows : Place two chairs at the side of an ordinary 
bed, with space enough between them to admit the 
lower bucket ; place a large pillow at the extreme side 
of the bed nearest the chairs, spread an ordinary rubber 
sheet over the pillow, so that one end of the sheet may 
fall into the bucket below, in the form of a trough, 
The douche may then be given with the patient's 
hips resting on the pillow and with one foot on each 
chair; the water -will then find its way along the 
rubber trough into the bucket below. 

VAGINAL SUPPOSITORIES. 

Medicated Pessaries. Usually the patient herself is directed to 
insert these, placing them in the vagina as far as the 
finger can reach. The vehicle employed is generally 
cocoa-butter. The following is a table of the average 
strength : 

Sedative Suppositories, 

Atropine, gr. -fa. 

Belladonna, (ale. extract, gr. ij. 

Opium, gr. ij. 

Morphia, gr. ss. 

Cicatrizing and Emollient. 

Bismuth oxide, gr. xv. 

Borax, . ' gr. xv. 

• Zinc oxide, gr. xv. 

Astringent. 

Alum, gr. xv. 

Alum and iron, gr. x. 

Alum and catechu, aa gr. xv. 

Acetate of lead, gr. viij. 

Acetate of lead and opium, gr. v., of opium gr. ij. 

Tannin, 

Matico, 



gr. x. 
gr. x. 



Gallic acid, gr. x. 

Hcemostatic. 

Perchloride of iron, gr. v. 

Persulphate of iron, gr. v. 



244 DISEASES OF VAGIXA, TJRETRHA AXD BLADDER. 



Caustic. 




Persulphate of zinc (dried,) 


gr. x. 


Antacid. 




Carbonate of soda, 


gr. xv. 


Disinfectant. 




Carbolic acid, 


gr. v. 


Alterative and Resolvent. 




Iodide of lead, 
Iodide of lead with atropine, 
Iodide of potassium, 
Bromide of potassium, 
Mercurial, (ung. hydarg.,) 


gr. v. 

gr. v., atrop. gr. £ s , 

gr. x. 

gr. x. 

gr. xxx. 



VAGINITIS (SPECIFIC, GONORRHEAL) 

In the gonorrhoea! form of vaginitis, the treatment recom- 
mended by 

J. T. DARBY, M. D., OF NEW YORK, 

Is almost exclusively local. (Archives of Clin. Surgery, June, 
1878.) Internal remedies are of no efficacy. The only proper 
treatment is a local one, and general treatment is only beneficial 
for the constitutional symptoms, or to make the urine less acrid 
and irritating, to relieve the pain in micturition. Alkalies given 
by the mouth answer the latter indication. 

In a severe case of the disease, absolute rest, elevation of the 
hips, and the use of some local remedies, will assuage the pain 
and inflammation. The only medicines to be administered in- 
ternally are to prevent the burning in the urethral tract. Dr. 
D. discards entirely copaiba, turpentine, and the like, as they do 
no good, while on the contrary they do harm by disturbing the 
digestion. 



VAGINITIS (specific, gonorehceal.) 245 

Lotions applied to the part itself act as a sedative, of which 
lead lotion is the best where there is a good deal of inflammation 
without very much suppuration. Direct the patient to sit over 
a vessel, and then by means of a fountain syringe inject the parts 
well. The continuous application of cold is sometimes very ben- 
eficial. If the bowels are constipated, give a laxative to cause a 
free action; common Epsom salts or seidlitz powder will do 
very well. We do not wish to cause a diarrhoea, but simply to 
produce a few active movements so as to help remove the con- 
gestion. 

The diet should be regulated so as not to be too stimulating. 
Rice and milk with stale bread may constitute the food until the 
fever has abated. If the fever runs high, we may give tincture 
of aconite, or the tincture of gelsemium semper vir ens. This 
latter is one of the best remedies for the purpose in this disease. 
This agent has no specific influence on the disease, but it simply 
reduces the constitutional disturbance produced by a local cause. 

Sometimes the discharge is very profuse. In such a case, use 
warm water for the injections instead of cold. Where suppura- 
tion is abundant, the warm injections act better, and, moreover, 
they are much more comfortable to the patient. In addition to 
the warm water injections, astringents may be used, such as 
acetate of lead or tannic acid. Opium may be combined with 
these remedies, as it tends to relieve the smarting they produce, 
and prevents pain by its direct action. 

Another remedy of considerable efficacy is chlorate of potassa. 
This may be used alone or in combination with the bromide of 
potassium. A very good prescription is the following : 

218. R, 



M. 



This is one of the best remedies to alleviate the pain and stop 
the discharge. 



Potass, chlorat., 






Potass, bromid., 


aa 


f> ss 


Aluminis, 




u 


Aquse fervent., 




Oij, 



246 DISEASES OF VAGINA, URETHRA AND BLADDER. 
JOHN MORRIS, M. D., OF BALTIMORE. 

This writer (Virginia Med. Monthly, August, 1878,) also be- 
lieves that local remedies are chiefly to be relied on, though he 
has found cubebs, administered internally, to prove very service- 
able, particularly if the urethra or bladder is involved. Cubebs 
exercise a specific effect on the raucous surfaces, even when taken 
into the general circulation. He has, therefore, used this drug 
with advantage in both leucorrhcea and specific vaginitis. The 
old-fashioned injection of sulphate of zinc acts very well in mild 
attacks, if supplemented by frequent injections of cold water. 
AVhen the urethra or rectum is the seat of the inflammation, 
nitrate of silver is our most potent agent. When the disease 
creeps into the cervix uteri, internal injections of nitrate of silver 
and glycerine are our best means of cure. These cases are very 
intractable, and peculiarly painful when the fallopian tubes and 
ovaries are included in the inflammatory process. Months, even 
years, are required ofttimes to effect a cure. In some cases, in- 
deed, the disease is incurable, and remains as a lifelong affliction. 
When gonorrhoea attacks the rectum, it is not only painful, but 
troublesome. Many weeks are required to effect a cure. It 
seems to exercise the same kind of virulence in this locality that 
it manifests when it attacks the conjunctiva, though, of course, 
the after-consequences are not so serious. 

DR. GAUDRIOT, OF PARIS. 

219. R . Zinci chloridi liquoris (Fr. codex,) gtt. v. 
Morphise sulphatis, gr. ss. 

Mucilaginis, 
Pulv. sacchari albi, 

Feculi, aa q. s. M. 

Make one suppository. To be introduced into the vagina and retained by 
a bandage. The vaginal secretions dissolve the suppository, and the active 
agents are brought into contact with the membrane. 



VAGINITIS (SPECIFIC, GONORRHEAL.) 247 

LAWSON TAIT, F. R. C. S., BIRMINGHAM. 

Acute gonorrhoeal cervicitis or endo-cervicitis, is full of anx- 
iety, for the disease may spread up the uterus and along the 
tubes to the ovaries. The patient must be kept rigidly in bed, 
and be treated by soluble pessaries of acetate of lead and opium, 
and general antiphlogistic remedies. On no consideration what- 
ever should injections be employed in such a case, either vaginal 
or intra-uterine. 

Gonorrhoeal acute ovaritis is a common result of the injection. 
There is agonizing pelvic pain, generally on one side, and all 
the signs of a severe inflammatory attack. Micturition and 
defecation are often accompanied with excruciating pain. By 
administering an anaesthetic, a vaginal examination will reveal 
the enlarged ovary. The treatment should consist in leeches to 
the perinseum, a blister over the ovaries, diuretics, and small, 
frequent doses of opium. The rectum should be well evacu- 
ated by an enema, and the bowels kept quiet for a few days. 

In cases of fading gonorrhoea, it is very common to find that 
pressure on the trigone gives a good deal of pain, and that the 
urine is alkaline and purulent. Injection of the bladder, in 
these cases, with weak solutions of carbolic acid or neutral ace- 
tate of lead, will very rapidly effect a cure. 

In acute gonorrhoeal urethritis, no application is so good as a 
morphia pessary; the chronic form, which is often left after the 
acute stage has passed, is very easily cured by the application of 
equal parts of carbolic acid and glycerine on a probe armed with 
cotton-wool. 

DR. MONTROSE A. FALLEN. 

This writer observes (Gaillard's Medical Journal, December, 
1879,) that the treatment of gonorrhoea in women is not the 
simple matter one would be led to suppose, upon reading the 
descriptions given in the majority of books. Injections pre- 
scribed, such as the zinc, alum, copper, and silver salts, are very 
slow, as well as inefficient in their work. The virus not only 
invades the genital folds of the vulva, but likewise the urethra, 



248 DISEASES OF VAGINA, URETHRA AND BLADDER. 

vagina, cervix-uteri, and even the uterine cavity and oviducts. 
He knows of nothing comparable to the excessive use of hot- 
water douching, in the initial symptoms of the disease, as the 
retention of the acrid virus in the folds of the vagina is apt to 
beget erosions of the mucous surfaces, which rapidly undergo 
ulceration.. Any method to prevent friction of the vaginal walls 
is beneficial, and as the common yellow clay, found in Pennsylva- 
nia, Missouri, and other states, is a most admirable antiseptic, as 
well as very soothing to inflamed surfaces, his practice is to 
thoroughly irrigate the vagina with hot carbolized water, place 
the patient in the knee-chest position, retract the perinseum with 
the Sims speculum, and after the vagina is balooned by atmo- 
spheric pressure, to thoroughly dry the surfaces with cotton, 
then paint them with a saturated solution of nitrate of silver, 
followed by a solution of common salt, to make an insoluble 
silver chloride, to prevent too much cauterization, then to dry 
the surfaces once more with cotton, and then fill the vagina with 
dry powdered clay, or a magma of clay, vaseline, and thymol. 
The clay is not only an antiseptic, but it protects the mucous 
surfaces from attrition, and is at the same time a pessary- mould, 
on which the uterus rests. Besides these advantages, it absorbs 
all of the gonorrhoeal discharge, and keeps the genital tract clean 
and free from smell. Twenty-four hours subsequently, the 
patient can wash everything out of the vagina by means of the 
hot-water douche, and the nitrate of silver, etc., may be re- 
applied. 

M. Vidal, of Paris, uses gurjun balsam, locally, the vagina 
being first w r ashed out with warm water, a plug of cotton-wool, 
soaked in a liniment of equal parts of balsam and lime-water, is 
applied by means of the speculum, and the plug is then covered 
with a second one of dry wool. 

JOSEPH MULREANY, F. R. C. S., ENGLAND. 

Gonorrhoeal Metritis. Where the gonorrheal inflammation ex- 
tends to the uterus, bringing on the complication of specific 
metritis, this writer {Half -Yearly Compendium, vol. VIII.,) pre- 



VAGINITIS (SPECIFIC; GONORRHCEAL.) 249 

scribes at the outset, dry heat to the abdomen, and internally, a 
combination of the alkaline carbonates, iodide of potassium, and 
opium, in large and repeated doses, such as in the following 
formula : 

220. R 



Pulv. potass, bicarb., 




^ij. ad giij. 


Pulv. potass, nitratis, 




gij. ad 3iss. 


Sp. am in on. aromat., 




f.^vj. ad f.5 j. 


Potassii iodidi, 




rcss. ad ^j. 


Syrupi zingiberis, 




f-lj- 


Aq. pur., 


adf 


Jvj. M. 



A tablespoonful to be taken every one, two, or three hours, during the ur- 
gency of (he symptoms. 

Sometimes he gives a dose of calomel, gr. v. ad gr. x., if there 
is a bilious taint either of skin or breath. Rarely are leeches 
necessary ; and at this stage he never uses injections. Within a 
few hours marked relief is obtained. The opium dominates the 
pain, and frees the system from its depressing influence : and the 
beneficial actiou of the alkalies on the blood, in this, as in n any 
acute inflammatory affections, is most marked. He gives no 
alcoholic stimulants, and restricts the patient to a purely milk 
diet. 

The above treatment requires very little alteration in most 
cases, till a cure is effected. Another point in this plan is that 
the bowels are kept quiet. If they do not act for three or four 
days, so much the better, as by that means the inflamed and 
enlarged uterus is neither pinched nor disturbed by excessive 
peristaltic movement ; they of themselves, however, act about 
the fourth day ; but if they do not, a dose of sod. et potass, tart, 
and rhubarb is sufficient to effect that object. 



250 DISEASES OF VAGINA, TJKETHRA AND BLADDER. 



VAGINISMUS AND DYSPAREUNIA. 

This common and distressing affection is frequently a neurosis, 
without visible cause ; but it is also, at times, owing to herpes, 
vaginal fissure, hypertrophied and painful papillae, mucous patches, 
or disease of the urethra. These various conditions require ap- 
propriate treatment. 

PROF. J. MATTHEWS DUNCAN, M. D., LONDON. 

In simple, pure neurotic cases of vaginismus, there is no 
treatment which is of decided use. Enlargement or distension 
of the vaginal orifice only slightly, or not at all, modifies the 
disease. Even the distension caused by childbirth has no good 
effect. In a bad case of this kind there is no absence of the dis- 
ease when sexual relations are resumed. Cutting of the pudic 
nerve might be tried, but has been performed without benefit. 
Cutting away the sensitive parts is useless ; alleged cures from 
this proceeding are misinterpretations. 

In instances occurring soon after marriage, there can often be 
discovered a painful red spot at the fourchette, and occasionally 
also a fissure there, or near there. Time and rest are all that are 
required in these cases, the rest meaning a separation of the mar- 
ried parties. If prolonged, childbirth will cure these cases. 

Another frequent cause in newly-married women is vaginitis, 
either acute or chronic. The treatment appropriate to these in- 
flammatory conditions will, when successful, also remove the 
painful spasm. 

Another not uncommon local cause, and one apt to be over- 
looked, is the presence of one or more little ulcerations, situated 
around the orifice ©f the vagina beyond the hymen. They are 
intensely tender and sensitive, and are probably allied to eczema 
or lupus. They should be removed either with the knife or the 
cautery ; but the success attending these operations has not usu- 
ally been of a kind to boast of. 



VAGINISMUS AND DYSPAKEUNIA. 251 

DR. H. HILDEBRANDT, OF KONIGSBERG.* 

Professor Hildebrandt condemns the treatment of vaginismus 
by forcible dilatation, whether under anaesthetics or not. The 
course he directs is to begin by a removal of any local cause of 
the reflex spasms, and then to proceed to methodical gradual 
dilatation. 

These local causes may be as follows : 

Local inflammatory affections, as eczernatous, or erythematous 
conditions of the introitus vaginas; inflamed carunculse myrti- 
formes ; sensitive cicatrices of the hymen ; urethritis, etc. These 
may generally be removed by fomentation with warm lead-water, 
by touching with nitrate of silver or tincture of iodine, or by re- 
moving painful cicatrices or carunculse with the knife or scissors. 

Affections of the uterus or ovaries, especially forms of chronic 
inflammation of those organs. These, at times, lead to reflex 
spasms of the muscular floor of the pelvis. They must receive 
appropriate treatment before we can hope to cure the vaginismus. 

The dilatation should be begun only after the above local 
causes have received attention. At first only small specula 
should be employed. When coition begins, it is important to 
instruct the husband to be moderate and careful ; and the fear of 
the act on the part of the woman should be allayed by assurances 
that there is no danger of the suffering returning. 

In all cases the following, introduced every evening, will be 
well to try : 

221. B • Butyri cacao, 4 grammes. 

Pota?sii bromidi, 50 centigrammes. 

Belladonna extracti, 30 " 

Acidi thymici, 5 M. 

For a vaginal suppository. 

He believes the medical treatment alone is generally sufficient 
to effect a cure. The parts should be carefully examined for 
any fissure or ulceration. If present, they are to be cauterized 

* Part VIII. of Billroth, Handbuch der Fraucnkrankheiten. 



252 DISEASES OF VAGINA, URETHRA, AND BLADDER; 

with nitrate of silver, tincture of iodine, or powdered with iodo- 
form. Dilatation, either gradual or forced, may be necessary, 
but our author believes that this is very rarely the case. Nearly 
all such patients require, in addition to the local treatment, such 
general tonic measures as iron, quinine, mineral waters and mas- 
sage. 

F. WEBER, M. D., OF ST. PETERSBURG, 

Has found (AUg. Med. Zeitung, January, 1878,) that the most 
common causes of the affection, he thinks, are a rigid condition 
of the hymen, gonorrhoeal or catarrhal inflammation of the vagina, 
and also ' cicatrices, ulceration or excoriation of the vulva and 
outer parts of the vagina. 

Organic contraction should be treated by methodical dilata- 
tion, at first with compressed sponge, and subsequently with 
Ferguson's specula, the size of which should be gradually in- 
creased. An ointment of belladonna is of great service at the 
same time. Inflammation of the vagina should be treated with 
cloths wet with a solution of sugar of lead, injections with or 
without opium, and belladonna suppositories. In the latter 
stages, cauterization, with a solution of nitrate of silver, gives 
excellent results. This is especially serviceable when there are 
excoriations. Warm hip-baths lessen the irritability of the 
nerves, and are of service. In addition to the local treatment, 
tonics and nervines should be used — especially bromide of potas- 
sium, iron and valerian. When no local trouble is to be found, 
and the sufferings of the patient are very severe, division of the 
nervus pudendus, as recommended by Simpson and Sims, should 
be practiced. The removal of the hymen itself or the myrtiform 
caruncle, Weber has never fouud necessary, though it has been 
repeatedly done by Sims and others. 

M. T. GALLARD, M. D., OF PARIS, 

Recommends, where there is redness or excoriation of the mucous 
membrane, an iodoform ointment, as : 



VAGINISMUS AND DYSPAREUNIA. 253 

222. R . Iodoformi, 

01. theobroma?, aa. gss. 

Axungise recentis, 3 iv. M. 

If there is only pain, without any apparent alteration of the 
mucous membrane, he prescribes : 

223. R. Ext, belladonna?, gr. xlv. 

Axungise recentis, aa gr. xlv. M. 

In either case, he directs to be made plugs of charpie, as 
small as they choose to commence with ; and in order not to 
frighten the patient, he charges her with the making of them, 
instructing her to count the threads which enter into each of 
these plugs, to be introduced into the vagina each night, after 
being anointed with one or the other of the two ointments men- 
tioned above. If at first she uses the iodoform, she will be 
able, after a few days, to replace it by the belladonna, when the. 
redness or excoriation, or the eruption of the vulvar region, 
has disappeared. Only, in either case, care must be taken to 
increase each day, by an imperceptible amount, but previously 
determined, the number of threads employed — -ten, twelve, or 
fifteen, for example. So we shall secure, after a time, which 
which will never be very long, the use of a plug of such size as 
that, after having removed it, the place may be supplied by the 
virile member without the substitution causing any pain: He 
attributes the cure in these cases chiefly to the narcotic action of 
the unguents applied, though not denying that there may be 
advantage in the mechanical effect of the dilatation also. 

He utterly condemns all use of the knife in such cases, unless, 
possibly, when the carunculse myrtiformes are inflamed, swollen, 
or ulcerated, when he would sometimes admit the ablation of 
these as a more speedy mode of cure than treatment by caustic 
only. 

DR. EUGENE BOUCHUT, PARIS. 

224. R . Extract! kramerise, g as. 

Butyri cacoae, 3 j. M. 

Make twelve suppositories. One to be introduced into the vagina night 
and morning. Valuable where there is vaginal fissure. 



225. B=. Argenti nitratis, 
Aquas destillatse, 


gijss. 


Or with : 




226. R. Acidi carbolici, 
A quae, 


gr. x. 



254 DISEASES OF VAGINA, URETHRA AND BLADDER. 
PROFESSOR CARL SCHROEDER. 

Bathe the external genitals cautiously with dilute lead- water, 
and afterward, when the redness has subsided, pencil the sensi- 
tive parts with : t 



M. 



M. 

This was also the treatment preferred by Prof. Scanzoni, and 
in many instances it is entirely successful, and dispenses with 
the severe surgical measures introduced by Simpson, Sims, and 
Others. 

W. H. BYFORD, M. D., CHICAGO. 

This writer treats vaginismus by applying the solid nitrate of 
silver to the vulva every ten or fourteen days, and in the inter- 
val, glycerine and tannin. The first application reduces the 
sensitiveness decidedly, and it becomes less after each successive 
touch until finally cured. Rational general treatment should 
always accompany this local one. 

Mr. I. Baker Brown has noted that hyperaesthesia of the 
vagina is occasionally dependent on diseases of the rectum, espe- 
cially fissure, and disappears when this condition is removed. 
(Surg. Dis. of Women.) 

As parturition would almost certainly relieve this condition, 
a simple and sure cure could be effected by fertile coition, car- 
ried out when the patient was thoroughly under the influence 
of ether. 

KESUME OF EEMEDIES. 

Aeidum Oarbolicum. (See F. 226.) 
Argenti Nitras, locally applied. (P. 225.) 
Atropia, Dr. Peaslee recommends : 



VAGINAL GROWTHS. 255 

227. R. Atropiag, g-r. ij. 

Adipis, 3J. M. 

For local use. 

Belladonna is useful at times. (F. 221.) 

Ice. The application of finger-shaped pieces of ice in the vagina 
is recommended by Holst. 

Iodoformum is praised by Leblond and others. It may be 
given in suppositories, each containing gr. x. 

Krameria has been employed by Bouchut. (F. 224.) 

Opium. A full dose of opium, or a hypodermic injection of 
morphia, will sometimes relax the spasm of the con- 
strictor muscle, and relieve the symptoms. (Fonnsa- 
grives.) 

Plumbum. Goulard's extract is often exceedingly soothing. 

Stramonium is occasionally beneficial. 



VAGINAL GROWTHS. 



The vegetations and warts which form on the labia may be 
removed by the knife or scissors. Dr. E. J. Tilt uses the lat- 
ter, and touches the seat of growth with acid nitrate of mercury. 
The application to them of crystallized acetic acid is said to 
remove them without pain. 

For caruncle of the urethra, Dr. "Wm. Goodell recommends 
the actual cautery, as a red-hot knitting needle. The after-treat- 
ment is the application twice a week of the undiluted commer- 
cial carbolic acid, which will prevent a crop of small growths 
springing up around the site of the parent growth. When the 
patient will not submit to the knife or the cautery, the next best 
procedure is to touch the growth twice a week with crystallized 
carbolic acid made fluid by heat. 

Dr. A. W. Edis recommends (Brit. Med. Jour., April, 1874,) 
a saturated solution of chromic acid in these growths, applied as 



256 DISEASES OF VAGINA; URETHRA AND BLADDER 



above mentioned for carbolic acid, and afterwards neutralized by 
pledgets of lint dipped in a strong solution of sodium carbonate. 

For non-syphilitic warts and papilomatous growths of the 
vulva and parts adjacent, Dr. Henry G. Piffard, of New 
York, (note to Phillips' Materia Medical) has used with the 
utmost satisfaction a strong tincture of the arbor vitce, Thuja 
occidentalis, applied to the part three times a day for a week or 
fortnight. 

Dr. Graily Heayitt suggests the use of strong nitric acid 
or lunar caustic. Black wash, or a strong solution of iodide of 
potassium, should then be applied. 

Dr. G. S. Bedford removes these excrescences, or when small, 
sprinkles them once a day with : 

22S. R . Cupri acetatis, 

Sabinse, aa gr.vj. M. 

Dr. F. J, Bumstead removes these growths, or, when quite 
small, touches them with glacial acetic acid, or fuming nitric 
acid; as the eschar falls, repeating as may be necessary. In 
obstinate cases, he employs a solution of chromic acid 100 grains 
to the ounce. Or, corrosive sublimate in collodion 3j. to f. 5j., 
may be applied over the whole surface. The perchloride or sub- 
sulphate of iron often proves useful, applying it once or twice a 
day to the growth, wdiich shrivels and falls, and a few applica- 
tions will prevent its return. 

Where vegetations are flat and horny, Zeissl gives : 

229. R. Acidi arseniosi, gr. ij. 

Ung. hydrarg., gj. M. 



Or 



230. R. Arsenici iodidi, gr. ij. 

Ung. hydrarg., 5j. M. 

Dr. Peters, of Prague, has found the simple application of 
cold poultices to cause these growths to disappear, after they had 
resisted cauterization and even excision. 



PRUEITUS VULVAE SEU VAGINA, AND VULVITIS. 257 

Vuivo- Vaginal Cysts. The glands of Bartholin are at times 
liable to become encysted, and lead to the formation of small 
tumors, often painful. Their contents may be withdrawn, but to 
prevent them from refilling Dr. E. Dtjvemoz recommends that 
they be injected with about six drops of a ten per cent, solution 
of chloride of zinc. (Annates de Gynecologic, April, 1880.) 



PRURITUS VULVAE SEU VAGINA, AND VULVITIS. 

The most common causes of itching of the vulva are pediculi, 
irritating vaginal leucorrhcea, dilatation of the lymphatic vessels, 
eczema, erythema, diabetes, pregnancy, vesical calculus, herpes 
tonsurans, abnormal growths, cervical endometritis, the presence 
of small bristly hairs on the vulva, seat worms, leptothrix vag- 
inalis and simple nervous pruritus. It is generally symptomatic. 
In all cases the treatment, when practicable, should be with 
reference to the causation in the particular case. 

PROFESSOR CARL SCHROEDER. 

Of actual curative agents, this writer (Ziemssen 's Cyclopaedia) 
can only speak speak with confidence of: 

231. B: . Acidi carbolici, gtt. iv.-l. 

Glycerinae, 

Aquse, aa f. ^ ss. M. 

Apply locally. 

He says of this combination : " I am sure that whoever has 
once tried this, will never return to any of the other remedies 
which have been recommended." 

A. C. GARRATT, M. D., BOSTON. 

232. R. Acidi hydrocyanici (Scheele's,) f . ^ ij . 

Liquoris plumbi subacetatis, f. % iv. 

Aquae, f. ^ iij. M. 

As a local application. 

17 



258 DISEASES OF VAGINA, URETHRA AND BLADDER. 

Dr. Horatio R. Storer, of Newport, R. I., states that he 
has long given great comfort in this affection by Oldham's oint- 
ment of hydrocyanic acid and acetate of lead, with cocoa butter. 

Dr. G. S. Jones, of Boston, has employed with benefit, in 
pruritus of the vulva, the following : 

233. R. Sodii biboratis, g j. 

I amphorae, 5jj. 

Olei gauliherise, gtt. xxx. 

Aqua? bullientis, Oij. M. 

"When cool, pass through a cloth. To be used cold, as a wash for the parts, 
and as an injection into the vagina. 

For pruritus, produced by irritating leucorrhceal discharges, 
Dr. A. R. Jackson, of Chicago, has used, with gratifying 
results, the following : 

234. R . Zinci sulpho-carbolatis, % ss. 

Aqua?, f.Jviij. M. 

Wash the parts twice daily, leaving it to dry upon the surface. 

PROF. MONTROSE A. PALLEN, M. D., NEW YORK. 

This gynecologist has found pruritus pudendal is in pregnancy 
to yield in nearly every instance, except when it depends on 
trophic neuric causes, to the application of thymolized clay. 

235. R. Thymol, gr.xv. 

Vaseline, gr. xxx. 

Powdered brick clay, J iij . 

Dissolve the thymol in the vaseline, and rub it up with the clay. 

This is introduced into the vagina or applied to the pruritic 
parts, to be washed out every day or two and replaced. Herpes, 
eczema, and kindred affections, so often encountered in the later 
months of gestation, are similarly benefited by this antisepsis, 
more particularly if produced by the acrid discharges from the 
cervix and vagina. [Richmond and Louisville Med. Journal, 
1878.) 

In diabetic cases, Professor Winckel [Practitioner, Septem- 



PRURITUS YTTLYJE SUE VAGINA, AND VULVITIS. 259 

ber, 1876,) states that by the administration of Carlsbad salts 
internally, and a salicylic acid lotion externally, he can generally 
effect a cure. 

Dr. B. Hicks (Lancet, vol. L, 1877, p. 456,) has made some 
good observations upon the same subject, and also on the very 
frequent association of eczema with diabetes. Codeia has proved 
most valuable, in Dr. Hicks' hands, in allaying the irritation. 
Nothing approaches in value, according to Dr. Richard Neal, 
of London, a solution of boraeic acid as a local application. 
Professor Hardy (Medical Times and Gazette, July, 1877, p. 98,) 
reports on pruriginous and other affections of the genitals in both 
males and females as symptoms of diabetes. That such symp- 
toms are frequently associated with diabetes is certain. Well- 
marked instances of pruriginous vulvitis, where no trace of sugar 
exists in the urine, are, of course, of frequent occurrence. 

DR. ALFRED WILTSHIRE, OF LONDON. 

The treatment adopted by this writer is set forth in the Brit- 
ish Med. Journal, March 5th, 1881 : 

Attention to cleanliness will often do much to allay irritation, 
and should always be enjoined. Demulcent washes are prefera- 
ble to soap, unless carbolic or coal-tar soap be used, and usually 
even these are inadmissible. Almond-meal, strong bran-water, 
decoction of rice, marsh-mallow, slippery-elm, or fine oatmeal, 
are suitable, especially the first, which, if pure, yields, during 
use, a marked odor of hydrocyanic acid, and appears to soothe 
materially. 

When pruritus is due to acari or pediculi, ointment of sul- 
phur, white precipitate, or stavesacre, speedily cures, by destroy- 
ing the insects and their ova. If nits persist about the pubic 
hairs, a lotion containing bichloride of mercury and acetic acid 
will dissolve them. Ascarides are destroyed by a carbolic lotion 
(1 in 60), but general, rather than local treatment, should be 
relied upon for their eradication — iron, quinine, cod-liver oil, 
together with enemata of hamamelis, lime-water, iron, etc. 



260 DISEASES OF VAGINA, URETHRA AXD BLADDER. 

The vegetable parasites are very efficiently treated by unirri- 
tating parasiticides, e. g., borax, boracic acid, sulphurous acid, 
etc. Most of the favorite remedies for vulvar pruritus are para- 
siticides. 

It is a curious clinical fact that patients are often freed for 
days from itching, by a single application of a parasiticide, as 
after the use of a strong borax lotion. It is best to use such 
remedies in a fluid form, for, when necessary, powerful combi- 
tions may thus be made in the unhappily intractable cases. 
Fatty preparations of drugs do not suit so well for local applica-' 
tion as non-fatty, and yet great relief may be afforded by some 
ointments. 

Many cases of pruritus vulvae are promptly relieved by a 
borax lotion, and it is well to use this simple and efficacious 
remedy where not contra-indicated. A drachm to five ounces 
of warm water is a good standard strength, but a stronger solu- 
tion is usually needed, seldom a weaker. Hydrocyanic acid may 
be added, say 3 j. of the dilute acid to f x., or morphia (gr. ij.,) 
atropia (gr. ss), aconitia (gr. ss.,) or veratria (gr. ss.) Infusion of 
tobacco (half an ounce to the pint) alone relieves some cases, 
and forms a good vehicle for borax or boracic acid. It is not 
well to use glycerine with the borax, as a rule, as it is apt, 
owing to its affinity for water, to aggravate the irritation. Some 
find relief from chloral lotions, but the drug has not always 
suited. Strong decoction of poppy is a soothing vehicle for 
borax, etc. Ice alone will relieve some, while others can get 
relief only from the use of very hot water. 

Boracic acid is an excellent remedy, but, being much less 
soluble in water than borax, it is not so handy as a lotion. It 
may be combined with hydrocyanic acid, morphia, atropia, aco- 
nitia, veratria, etc. In the form of ointment, where fats do not 
disagree, it often soothes greatly. A non-rancid fat should alone 
be employed as the vehicle, e. g., freshly-made spermaceti cerate, 
vaseline, fossiline, or purified benzoated lard, etc. 

Lotions of iodine occasionally answer, e. g. y two drachms of 



PEURITIS VULViL bEU VAGIXJE, AND VULVITIS. 261 

iodine in ten ounces of elder-flower water. Electricity may 
afford relief in neurosal ca^es. 

In simple vulvitis, lead, borax, or carbolic lotions relieve. An 
ointment of calomel or bismuth is also good. Malignant affec- 
tions of the parts call for appropriate treatment, such as abla- 
tion, where practicable, but sedative applications (conium, opium, 
belladonna,) alone are often all that we can employ. 

Urethral caruncles should be removed, and urethritis, gonor- 
rheal, or other, treated in loco. Cystitis, stone, and kindred 
vesical affections and renal diseases, must be treated according to 
their several indications. Success is unattainable if they be 
overlooked. Vaginitis, gonorrhoeal or otherwise, demands thor- 
ough treatment. The packing of the upper part of the vagina 
with a tampon soaked in glycerine, with carbolic acid, lead, 
tannin, chloride of zinc, or borax, seems the most prompt method 
of cure, but the injections of these agents may suffice, and may. 
be preferable. When the itching is associated with chronic 
metritis, iodized tampons are useful, and so are copious irriga- 
tions of the parts with warm water. 

When vulvar irritation arises from acrid discharges proceeding 
from the uterine cervix or cavity, the use of a tampon filling the 
top of the vagina is most efficient. Cotton-wool, iodized or car- 
bolized, answers well. As glycerine is apt to excite a watery 
flux, it is not always admissible, but may now and then be 
required. Absorbent wool) dusted with iodoform, boracic acid, 
morphia, tannin, camphor, chloral, and such like, may be packed 
against the cervix uteri, so as to arrest and disinfect virulent dis- 
charges; the choice of drug being guided by the form of disease 
present. It is necessary to attach a string to each tampon to 
facilitate its withdrawal. Vaginal and pudendal pruritus, arising 
from acrid uterine discharge, is mostly seen in elderly women, 
and may be accompanied merely by glazy redness around the 
ostium vaginse. Search for uterine discharge may, therefore, be 
necessary. 

Local treatment by the tampon may be demanded in malig- 
nant disease in the uterus, and also in fibroids and polypi when 



262 DISEASES OF VAGINA, TTEETHEA AND BLADDEE. 

accompanied by irritating discharge, e. g., in disintegrating cal- 
cified growths. Removal of the diseased structures is preferable 
where practicable ; and the same may be said of cases dependent 
upon ovarian growths. Urticarious itching is the form of puden- 
dal irritation mostly seen in association with ovarian tumors. A 
lotion of bicarbonate of soda, or one of borax with hydrocyanic 
acid, generally relieves. Magnesia internally is useful. When 
there is previous tumescence of the vessels of the part, as may be 
seen from stasis in some pelvic effusions, relief is afforded by the 
watery flux provoked by the presence of a well-soaked glycerine 
tampon; and a mercurial and saline purge is helpful when por- 
tal congestion is present. Eczema, often symptomatic of glyco- 
suria, may be very obstinate. Dusting freely with fine oxide of 
zinc answers well when ichorous weeping is abundant. If fissure be 
present, a poultice formed of the clot resulting from the addition 
of two drachms of liquor plumbi to ten ounces of new milk is 
most useful. Sometimes calomel ointment will alone relieve, as 
in certain instances of anal mischief; or bismuth may answer, 
dry or otherwise. Mercurial ointment suits certain cases excel- 
lently. 

Angry ecthymatous spots appear to yield only to calomel, 
either dry or in the form of ointment or of black wash. Opium 
is a valuable adjunct, both internally as well as externally. 

Herpetic eruptions are benefited by a small mercurial dose fol- 
lowed by a saline purge, as the effervescent sulphate of soda, and 
the local use of borax lotion. If they be very severe, hydro- 
cyanic acid and other local sedatives may be necessary ; but it 
must be borne in mind that these herpetic manifestations gen- 
erally run a definite course, the vesicles dying away completely. 

Unhappily, we have no cure for confirmed diabetes, but much 
may be done by judicious treatment and management, alike for 
those who are threatened with gyclosuria, as for advanced cases. 
Immense comfort may be secured by the habitual use of cleans- 
ing ablutions, and of borax or boracic acid. 

Gouty diabetics may experience much benefit from a course of 
the Bath waters and baths, or from those of Carlsbad, The in- 



PRURITUS VULVAE SEU VAGIN.E, AND VULVITIS. 263 

somnia of diabetic pruritus vulvae sometimes shows a gratifying 
amenability to codeia, in the form of one-grain doses in pill. 
The bromides are also useful as hypnotics. 

The distress that pregnant women sometimes experience, 
especially towards the latter months, may be terrible. When 
associated with apthous ulceration, and the oidium albicans is 
present, nothing relieves more quickly than a lotion of sulphurous 
acid. Some prefer the hyposulphites, and in either case pro- 
lunged use is undesirable. As sulphurous acid is very volatile, 
it is best to mix a tablespoonful of the pharmacopceial solution 
with a half pint of warm water, barley-water, or almond emul- 
sion, freshly for each occasion. Another very useful lotion is 
formed by two drachms of bicarbonate of potash in half a pint 
of water. This should also be injected into the vagina ; it checks 
the discharge, often alkaline, which seems to excite irritation. 
Borax is again a valuable agent, and so is lead. 

In some cases, relief is only obtained after treating the cervix 
uteri ; as wdieu apthous ulceration is seen around the os. Nitrate 
of silver, lightly used, suffices. Bromide of ammonium inter- 
nally is highly serviceable. Attention should be paid to the 
state of the bowels, and to the hepatic and renal secretions, for 
in many cases elimination is defective. Turkish or hot-air baths 
exert a better effect over some of these cases than any ordinary 
treatment ; and the same remark applies to certain other varieties 
of pruritus vulvae, e. g., those seen in the obese, gouty and 
(senile) pruriginous. Jaborandi may prove very helpful under 
similar circumstances, by producing profuse diaphoresis. Diur- 
etics — -juniper, broom, potash, lithia, etc. — are often beneficial, 
as in gouty cases, especially when combined with colchicum. 
Restrictions as regards meat, beer and wines should be imposed 
on the subjects of lithiasis. 

When vulvar pruritus appears to be part of a general prurigo 
senilis, besides the local applications already indicated, a lotion 
of bromide of potassium may afford ease, as has been shown by 
Dr. Gueneau de Mussy. The same drug given internally is 
helpful, the affection appearing to be part of a general nervous 



261 DISEASES OF VAGIXA, URETHRA AND BLADDER. 

erethism. Arsenic exerts a controlling effect in some instances 
of senile prurigo, as well as in those due, as the French allege, to 
the dartrous diathesis. 

Arsenic may be said to be indicated in the neurosal forms, and 
especially when there is marked loss of flesh. 

In the intractable cases, frequent changes of remedies may be 
inevitable for the relief of torment. Chloroform locally applied 
answers occasionally; it may be used in the form of vapor, lin- 
iment, ointment, or lotion. Bichloride of mercury, also a par- 
asiticide, gives relief to some in the form of a lotion, but it re- 
quires caution in its use. Used in the proportion of gr.j-v. to 
§ viij. of mistura amygdala?, it may afford great relief. 

DR. L. DE SINETY. 

In almost all cases of simple vulvitis, repose, baths and emol- 
lient lotions constitute the whole treatment. After the acute 
stage has passed, slightly astringent lotions, as weak solutions of 
alum or tannin, are useful. When there is a blenorrhagic com- 
plication the inert powders, as oxide of zinc or subnitrate of bis- 
muth, are always grateful. Weak carbolic lotions will hasten 
the cure, and if long delayed the parts should be painted with a 
fifteen-per cent, solution of nitrate of silver. 

In cases of gangrene, poultices of powdered cinchona, or of 
oak bark and carbolic acid, are required. Iodoform in powder 
is also an excellent topical application. In the spontaneous gan- 
grene of the vulva in infants, it has been recommended to cau- 
terize the affected part, and a little beyond, with strong acids, as 
the hydrochloric. 

The oedema of the vulva, especially noticed in pregnant women, 
may be relieved by numerous small punctures, though this plan 
is not wholly free from the danger of erysipelas. In these cases 
the urine should always be examined for albumen ; and some- 
times they may be relieved by maintaining the horizontal 
position. 



PRURITUS VULVJE SEU VAGINAE, AND VULVITIS. 265 



DR. H HILDEBRANDT, OF KOXIGSBERG 



* 



236. &. 


Potassii bromidi, 


gr. xxx. 




Hydrarg. chlor. mitis, 


gr. xlv. 




Lupulinse, 


gr. xxx. 




Olei olivarum, 


gj- 


local use. 







Pruritus Vagincs. Of prime importance in obstinate cases, is 
a careful regulation of the life. The diet should be light, prin- 
cipally of vegetables, without stimulants, and the bowels regu- 
lar. The bed should be cool, and the genitalia frequently 
washed, but cold sitz-baths are not advantageous. During the 
night a compress, wet with black wash, should be applied, and 
during the day the parts should be anointed with equal parts 
unguentum plum hi and unguentum belladonuse. Or the follow- 
ing, especially in girls with a tendency to masturbation, will be 
efficient : 



M. 



When the sleep is disturbed by the itching in spite of these 
applications, Beigel strongly recommends a hypodermic dose 
of morphia; but our author has found decidedly more improve- 
ment from twenty or thirty drops of tinct. cannabis indica than 
from any other anodyne. 

All these and most other measures fail in not a few obstinate 
cases. In such the anti-pruritic applications extolled by various 
authors may be tried, but will often prove of no avail. In these 
we must have recourse to more decided measures. Of these, Dr. 
H. has derived signal advantage from two. They are cauteriza- 
tion with solid nitrate of silver and the use of the alum tampon. 
He takes a tampon or wedge of wadding and anoints it thoroughly 
with the following : 

237. R. Aluminis, gij.-iij, 

Adipis, Ifj. M. 

This is introduced into the vagina and allowed to remain six 
to twelve hours. It is then withdrawn and the cavity rinsed 

* Part VIII. of Billroth's Handbuch der Frauenkrankheiten. 



2Q6 DISEASES OF VAGINA, URETHRA, AND BLADDER. 

out with a mild alum injection. It is a modification of a method 
recommended by Scanzoni. 

Cauterization of the parts is performed by applying the stick 
freely to the whole upper part of the introitus, drying it with 
charpie, and counteracting the rather severe pain which gener- 
ally follows by cold compresses. 

Vulvitis. The general treatment of inflammations of the vulva 
involves repose, cleanliness, keeping the parts dry and prevent- 
ing friction. In acute catarrh of the vulvas, warm sitz-baths 
and fomentations with warm lead- water are required. In chronic 
cases, compresses wet with black wash, painting with nitrate of 
silver, and the use of lead or zinc ointment are called for. 

In certain obstinate cases, especially after gonorrhoeal catarrh, 
the inflammation persists in the glands of Bartholin and in the 
lacunas, which, to the number of fifteen or twenty, are found in 
the vulvar mucous membrane. Close examination will reveal a 
localized redness at these points. Direct treatment is here re- 
quired ; a pointed pencil of nitrate of silver is to be inserted into 
these depressions of the mucous membrane and their interior 
thoroughly stimulated. 

In vulvar folliculitis, a not uncommon form of vulvitis, appear- 
ing on the labia majora and leading to irritation, acne-like pus- 
tules, and even to small abscesses, the treatment should begin 
with warm sitz-baths, followed by warm poultices, the abscesses 
being opened early when they appear. 

Eczema Vulvas. The treatment of acute eczema in its first 
stage, consists in the application of warm poultices of bruised 
meal, which usually promptly diminish the burning pain, red- 
ness and tenderness of the skin. When these have disappeared 
the parts may be dusted with : 

238. R . Zinci oxidi, gr. xxiv. 

Amyli pulv., gj. M. 

When dry crusts have formed and there is no longer a fresh 
wet secretion, it will usually be sufficient to complete the cure 
by anointing with : 



PKUIilTUS VULVAE SEU VAGINA, AND VULVITIS. 267 

239. R . Hydrarg. praecip. alb., g jj. 

Axungise, 3J. M. 

For an ointment. 

The patient should be persuaded to keep her bed until the cure 
is complete, to refrain from scratching the parts, and if the itch- 
ing is unbearable she should be given an anodyne. 

In chronic eczema, the hard crusts should be removed by oil- 
ing and warm baths, or, in old cases, by covering the part for 
half an hour with compresses soaked in a solution of caustic 
potash, one part to three hundred of water. Following this, the 
white precipitate ointment should be applied. The tar prepara- 
tions are also useful in these cases. 

1>R. TAUSZKY, OF NEW YORK. 

In cases where the pruritus depends upon erythema intertrigo, 
acne, eczema, or prurigo, produced by vaginitis, or endometritis, 
this writer [Medical Record, September, 1880,) recommends 
warm injections of flaxseed tea, with a solution of the aqueous 
extract of opium, together with a sitz-bath, lukewarm, twice 
daily, for twenty or thirty minutes, and the subsequent irriga- 
tion of the vagina by means of a fountain syringe, and the fol- 
lowing : 

240. R • Zinci sulphocarbolatis, % ss. 

Aquse, 6ij. M. 

For an injection ; to be used every two hours, while the patient lies in a 
horizontal position, with her hips well raised. 

After each vaginal irrigation, a tampon of carbolized or sali- 
cylate! cotton, with some unguent and belladonna is introduced 
into the vagina so that it prevents the external parts from being 
bathed in the secretions, often mucous, sometimes muco-purulent 
— which cause the excoriations at and around the vulva, the 
nates, and the inside of the thighs — and directing the patient to 
use in the evening, and also for one hour in the afternoon, appli- 
cations of black wash — aqua phagedenica nigra. Where the 
pruritus or prurigo disturbs the patient's sleep, a hypodermic 
injection of morphia is given. 



268 DISEASES OF VAGINA, URETHRA AND BLADDER. 

The pruritus itself is greatly relieved, besides the above medi- 
cation, by application of dilute tincture of iron or a twenty per 
cent, solution of carbolic acid. The most useful of all applica- 
tions, however, for pruritus vulvae, is the balsam of Peru, of 
which the following formula is effective : 

241. R. Pulv. acaciae, gij. 

Balsarai Peruviani, gj. 

Olei amyg. dulc., 3.jss. 

Aqua? rosfe, Jj. M. 

Apply freely, with a camel's-hair brush, eight or ten times a day, to the 
itching part. 

This prescription was first suggested by Hueeland. If the 
pruritus vulva? is dependent upon diabetic urine, Dr. T. has 
found, in addition to the means herewith recommended, the 
daily internal use of from six to eight drachms of glycerine, in 
teaspoonful doses, extremely beneficial. If dependent upon 
granular vaginitis, he is in the habit of touching each granule, 
after first scraping it off with the curette, with an exceedingly 
fine point of nitrate of silver. 

DR. L. DE SINETY. 

Whatever treatment is adopted, it should be with a dne regard 
to the fact that the complaint is generally sympathetic of some 
other lesion. The following applications have proved the most 
useful in Dr. De S.*s practice. He adds that whatever lotion is 
used, it should be applied as hot as the patient can bear it. 

LINIMENTS. 

242. R. Chloroformi, gtt. xlv. 

Olei amygdal. dulc., 

Olei cadini, aa f . ^ vj . 

Tinct. opii, gtt. xv. M. 

243. R • Extracti opii, 

Extracd belladonna, aa gr. iij. 

Dissolve in the smallest quantity of water possible, and add : 
Potassii bromidi, £j. 

Glycerinse, t ^j. M. 



PEUEITUS VULVJE SEU VAGINAE, AND VULVITIS. 269 
LOTIONS. 

244. R . Hydrargyri chloridi corrosivi, gr. s.s 

Aluminis, ,5 V J- 

Glycerinae, 5 iij. 

Aquse destillatae, % x. M. 

245. R . Morphias muriatis, gr. j. 

Boracis, % iiss. 

Aqiue chloroformatse (saturat.), % x. M. 

Apply locally, several times daily. 

In some rebellious cases, a residence at a mildly alkaline and 
sulphurous spring, will bring about a cure. For those who 
cannot accomplish this, the following may be used at home : 

SULPHURO-ALKALINE BATH. 

246. R. Polysulphuret of sodium, % ss. 

Bicarbonate of sodium, 3j v. 

Water, for a bath. M. 

E. J. TILT, M. D., LONDON". 

Eczema Genitale. Irritation and pruritus of the genitals is not 
unfrequently owing to an eczematous condition of their surface. 
This is especially the case in fat women of middle age with 
gouty antecedents. As lotions or as injections, when the eczema 
extends to the inner surface of the vagina, the following prescrip- 
tions are recommended : 



247. R . Bismuthi subnitratis, 3 iij. 

Pulv. tragacanth., 3j. 

Aquse, O ss. M. 

Or, 

248. R. Zincioxidi, 

Calamine prep., aa gij. 
Acidi hydrocyan. diluti, 

Gycerinse, aa f. % ij. 
Liquoris calcis, adf.Jjviij. M. 



270 DISEASES OF VAGINA, URETHRA, AND BLADDER. 

Or, 

249. R. Zinci oxidi, gj. 

Glycerinae, 

Aquae calcis, aa f.^ j. 

Rub up the zinc with the glycerine, and add the lime-water. 

These lotions should be applied several" times a day, and the 
parts may be anointed with petroleum ointment. Constitutional 
treatment addressed to the diathesis is very important in these 
cases. 

Mr. Lawson Tait says of eczema of the genitals, that it is 
in some cases the most distressing disease he has ever witnessed. 
For its relief, it is necessary to determine whether it is due to 
the presence of parasites or of some irritating discharge from the 
vagina. He has repeatedly cured patients with chronic eczema 
of the genitals by first curing them of chronic endometritis. In 
elderly women of gouty diathesis, colchicum and acetate of potas- 
sa, continued for some months, have relieved some bad cases. 
Local applications are often useful, but what suits one may not 
another. Puff powder, the cold sitz-baths, simple cerate, Gou- 
lard's water, opiate fermentations, tarry preparations, etc., may 
be tried in turn. But the most generally useful applications he 
has found to be strong carbolic acid, and a concentrated solution of 
acetate of lead in glycerine. The carbolic acid must be used 
cautiously, and not over a large surface at one time ; or it must 
be used weak, and its strength gradually increased. He has re- 
peatedly seen one application of it relieve the patient for some 
weeks. If applied widely or in a concentrated form, the patient 
should be put under an anaesthetic. 

RESUME OF REMEDIES. 

LOCAL APPLICATIONS. 

Acidum Boracieum is praised in the diabetic form. (P. 259) 
Acidum Sulphur osum. Lotions and injections of sulphurous acid 



PRURITUS YULVJE SEU VAGI203, AND VULVITIS. 271 

have been found effective in casas dependent on vagi- 
nal discharges. 

Aconitia, in ointment, is approved by Dr. T. H. Tanner. 

Aluminii Nitras. Dr. Gill, of St. Louis, in the St. Louis 
Medical and Surgical Journal, recommeuds the use of 
nitrate of aluminium. It has in his hands, given more 
satisfaction than any other remedy. He orders four 
to six grains to the ounce of soft water, to be used as a 
vagina] injection or external wash, once or twice a day 
if necessary. 

Ammonii Murias, in the following ointment, is useful: 

250. R. Ammonii muriatis, %}. 

Pulveris helleboris albse, % ss. 

Adipis, % iij. M. 

ArnmonicE Aqua sometimes succeeds in obstinate cases like a 
charm, when injected in diluted form into the vagina : 

251. R. Ammonia? aquae. f.£ss.-j. 

Aqua;, O ss. M. 

To be freely injected into the vagina. 

Aqua Calcis, applied warm, together with perfect rest and 
light clothing, will sometimes afford the desired relief. 

Aqua Fervida. One of the most efficient means of relieving the 
pruritus occurring in pregnancy is hot water, applied 
by means of flannel cloths wrung out of that fluid and 
laid upon the parts. 

Argenti Nitras. Dr. Graily Hewitt, of London, states that 
in obstinate cases a rather strong cauterization of 
the os uteri, with the solid nitrate, will sometimes 
succeed when other measures fail. Dr. Charles 
(Annates de Gynecologic) also speaks most highly of 
the application of the solid nitrate of silver in the 
treatment of vulvar pruritus. The seat of the itching 
is oftenest near the clitoris, or in the nymphse, some- 
times at the margin of the anus. It is necessary to 
cauterize freely, passing the crayon two or three times 
over the affected surfaces, and even somewhat beyond 
them. Dr. Charles states that he has found, with- 



272 DISEASES OF VAGINA, "URETHRA AND BLADDER. 

out a single exception, great relief from the first cau- 
terization, often a complete cure. Sometimes it is 
necessary to recur to the cauterization a second or 
third time after some days. Dr. Tilt rubs the parts 
for several minutes with a piece of cotton soaked in a 
forty-grain solution of silver nitrate. 
Camphora, in powder, with starch, dusted over the parts, some- 
times removes the distressing symptoms. 

* Carbolicum Acidum is exceedingly efficient in very many 

cases. (F. 235.) 

* Chloral, by Prof. J. R. Black, of Ohio. 
Balsamum Peruvianum. An excellent prescription is : 

252. R. Chloral hydratis, giij. 

Aquae, f. ^ i v. M. 

Apply locally. 

In cases of pruritus vulvae, where the cause seems 
to be attributable to irritation, simply, of the nerves, 
whether in the pregnant condition or otherwise, Dr. C. 
O. Wright, of Cincinnati, (American Journal Obste- 
trics, July, 1879,) states that he knows of no remedy 
equal to the local application of chloral hydrate, either 
in solution or in the form of an ointment. Here it 
acts by direct contact, producing an anaesthetic influ- 
ence upon the peripheral extremities of the nerves, and 
acting by reflex action upon the nerve itself. 

253. R. Pulv. acacia?, ^ij. 

Peruvian balsam, 3J. 

Oil of almonds, % jss. 

Bosewater, §j. M. 

SiG. — Apply freely with a camel's-hair brush, eight or ten times 
a day, to the itching part. 

This latter prescription was first suggested by Hufe- 

LAND. 

Ergota, equal parts of the fluid extract and of glycerine, has 
proved effective in many cases. (Medical Annals, 
April, 1880.) 

* Chloroformum. Dr. Graily Hewitt, of London, obtains 

the greatest benefit from the application of: 



PRURITUS VULVAE! SEU VAGIXU, AND VULVITIS. 273 

254. R. Chloroformi, f.^ss. 

Olei amygdalae expressi, f. ^ iij. M. 

Creosotum. A weak solution is sometimes useful. 

Ferri Chloridl Tinctura, in varying strength, will often be valu- 
able. Byford recommends 3j. to water Oj., and 
adds that it is especially useful where there is no erup- 
tion, and when there is leucorrhcea and a congested 
dark appearance of the mucous membrane. 

Hydrargyri Oxidi Rubri Unguentum, well diluted with cod-liver 
oil, is frequently an effectual application. 

* Hydrargyri Chloridum Corrosivum. The favorite formula of 
Erasmus Wilson, of London, is the following : 

255. R . Hydrargyri chloridi corrosivi, gr. v.-x. 

Spiritus rosmarini, 

Alcoholis, aa f-^j- 

Misturse amygdalae amarse, f.^ vj. M. 

Another formula, said to be effective, is given by 
Dr. Milton. (Medical Press, March 11th, 1868) : 

256. R . Hydrargyri chloridi corrosivi, gr. iv. 

Bismuthi oxidi, gr. xxx. 

Acidi hydrocyanici diluti, HL xxx. 

Aquam calcis, ad f. J viij. M. 
Apply warm, twice or thrice daily. 

Hydrargyrum Chloridum Mite. A drachm of calomel in an ounce 
of lard is a soothing application. 

Hydrargyri Unguentum is advised locally, by Dr. Ringer, of 
London. 

Hydrocyanimm Acidum Dilutum is recommended, largely di- 
luted, by Dr. West, of London. It must not be 
applied too freely, nor over abraded surfaces : 

257. R . Acidi hydrocyanici diluti, ttLx.-xl. 

Glycerinse, f. § j. M. 

Iodininm. The tincture, locally applied, often affords relief. 
Iodojormum. An ethereal solution of iodoformum, used as a 

spray, or an ointment of iodoform, will often be found 

very serviceable, 

18 



274 DISEASES OF VAGINA, URETHRA AND BLADDER. 

Menthce Oleum or Essentia. In the Medical and Surgical Re- 
porter, vol. XL., 1879, a writer reports a most obsti- 
nate case promptly relieved by the occasional applica- 
tion of essence of peppermint. 

Morphia, subcutaneously, deserves trial in severe cases. 

*Olivo3 Oleum, spread over the parts with a feather, sometimes 
allays the pruritus. 

Fix Liquida. A glycerole of tar sometimes succeeds : 

258. R. Glycerine, 

Tar, aa J ft>. 

Starch, J oz. 

Heat the tar and glycerine separately, rub up the starch with the 
glycerine, mix, bring to the boiling point, and cool. 

Plumbi Subacetatis Liquor Dilutus. The following soothing ap- 
plication is a useful one : 

259. R. Liquoris plumbi subacetatis diluti, f.^j. 

Tincturse hyoscyami, f»3y« 

, Misturas camphorae, f.^viij. M. 

To be applied tepid. Rest and an antiphlogistic regimen are at 
the same time to be ordered. 



Potassii Carbonas, 3iij. to water liv., was recommended by 

Trousseau. 
Potassii Iodidum. When a syphilitic taint is present, this drug 

will often promptly remove the irritation. 
Sodii Boras. The following formula is advised by Dr. West, 

of London : 



260. R. Sodii boratis, %iv. 

Morphias muriatis, gr. viij. 

Aquae rosae, f. !§ x. M. 

Soda Chlorinatce Liquor, diluted, has been employed with suc- 
cess : 



261. R. Liquoris sod se chlorinatse, f-.^vj« 

Aquae, f.|xij. M. 



Sodii Sulphis has been favorably reported on : 



PRURITIS VULV^ SEU VAGINAE, AKD VULVITIS. 275 

262. R . Sodii sulphitis, % j. 

Aquae, f. ,^ iij. 

Glycerinse, f-|>j- M. 

Tabacum. Dr. Tanner recommends a lotion of an infusion of 
tobacco, 3 ij. to a pint of boiling water. 

Tanacetum. A poultice of tansey leaves, applied as hot as the 
patient can bear it, is said by Dr. R. L. Butt, of 
Alabama, to be efficient in obstinate cases. [American 
Practitioner j August, 1877.) 

Thymol may be tried. (See above.) 

Zinci Oxidum. For erythema and pruritis vulvae, Dr. Braun- 
Fernwald, of Vienna, recommends 

263. R . Unguenti petrolei, 5 grammes. 

Unguenti cetacei, 3 " 

Zinci oxidi, 3 " M. 

An ointment for local use. 



276 DISEASES OF VAGINA, URETHRA AND BLADDER, 



CYSTITIS. 

E. J. TILT, M. D. OF LONDON. 

The first thing to do in an attack of ordinary acute cystitis, is to 
put the patient to bed; give a warm hip-bath and warm vaginal 
injections ; and if the pain is severe, leech the abdomen and cover 
with an anodyne poultice. A rectal suppository of opium, gr.ij., 
will give ease, and gr. v.-x. of extract of hyoscyamus a day, in 
pill form, is not to be omitted. The urine should be rendered 
bland by alkalies, and the patient should drink freely alkaline 
and mucilaginous fluids. 

Cystitis may be caused by pelvic peritonitis, by tumors of the 
womb or ovaries, by prolapse, procidentia, etc. In such cases 
these conditions must be remedied before permanent relief of the 
vesical inflammation can be expected. 

A. J. C. SKENE, M. D., OF NEW YORK. 

Existing constipation should be overcome by the free use of 
saline laxatives. The diet should be carefully regulated. An 
exclusive milk diet has been found sufficient to cure some chronic 
cases. 

Benzoic acid is perhaps the drug that will be found the most 
useful in the earlier stages in the largest number of cases. It 
often seems to act as a specific, giving speedy and permanent 
relief. 

264. R. Acidi benzoici, 

Sodii biboratis, aa gr. x. 

Infusi buchu, f.Jij. M. 

This amount three or four times a day. 

The borax is added to insure the solution of the acid. Ben- 
zoate of ammonia is more palatable, and acts equally well in the 
same dose. 



CYSTITIS. 277 

In the more advanced stages of the disease, balsam of Peru, 
copaiba, and oil of turpentine, are important remedies. They 
should be given in capsules, the same as in gonorrhoea. When 
the pain is not severe and the urine is loaded with mucus and 
pus, astringents should be given, as the following, which Dr. S. 
has employed with good effect 

265. R. Extracti buchu fluidi, f. £ ij. 

Tincturse eonii, f'3.j- 

Morphias sulphatis, gr. iss. M. 

A teaspoonful every three or four hours. 

The salicylate of sodium and the sulpho-carbolates have been 
exhibited with advantage. 

In old and obstinate cases the bladder must be washed out and 
medicated injections used. Of these, the following may be em- 
ployed to relieve pain : 

266. & . Chloral hydratis, gr.x.-xv. 

Aquae, f. ^ j. M. 

For an injection in this proportion. 

As astringents and alteratives, nitrate of silver, sulphate of 
zinc, tannic acid, and acetate of lead, of either beginning with 
gr. i.-ij. to water f. ?j., are the most efficient. When the urine 
is alkaline and offensive from long retention, nitro-hydrochloric 
acid, gtt. ij. to water f. ? j., should be used. 

In obstinate cases, nitrate of silver, gr. xx. to water f. 5j., is 
one of the most reliable remedies. Of this strong solution not 
more than five or ten drops should be used at a time. 

As a last resort in painful and incurable cases, Dr. Emmet 
has established an artificial vesico- vaginal fistula, which main- 
tains complete drainage, and is sure to relieve, and perhaps will 
cure. The same object may be accomplished at times by a per- 
manent catheter. 

PROF. DR. F. WINCKEL, OF DRESDEN. 

This author (Handbuch der Frauenh-anlcheiten) begins his ob- 
servations on treatment by recommending the greatest care in 



278 DISEASES OF VAGINA, URETHRA AND BLADDER. 

cases predisposed to cystitis. The diet and drink should be mild, 
stimulants and acids avoided. Mild cathartics are preferable to 
injections, and the abdomen and lower extremities should be kept 
warm. Of special importance in puerperal cases is that each 
woman should have her own catheter. He believes that the use 
of a common catheter frequently extends the disease from patient 
to patient. 

When a catarrh of the bladder has once begun, the experience 
of many years has taught him that the local treatment is all-impor- 
tant. He begins with washing out the bladder with warm water, 
then with linseed tea, to which one part in a thousand of salicylic 
acid may be added. The injection should be the temperature of 
the body, and amount should vary from a quarter to one litre, 
according to age and size. This is to be repeated two or three 
times a day, and continued according to circumstances, perhaps 
for weeks. 

Should the above injections fail to answer the purpose, he 
would have recourse to those of nitrate of silver or tannin, as : 

267. R . Argenti nitratis, gr. i.-iij. 

Aquae, |j. M. 

268. R. Acidi tannici, gr. iij.-xv. 

Aquse, §j. M. 

He has never had occasion to use any other means than the 
above in order to effect a cure. The balsams, especially copaiva, 
he has not been called upon to try. 

It is of great importance in the treatment of this disease that 
the patient be not permitted to retain her urine for any long 
time. She should be obliged to empty the bladder at regular 
intervals, and unless it is completely done the catheter should be 
inserted. General warm baths are very grateful, and as drinks 
she may use milk of almonds and Vichy, soda or other alkaline 
waters. 

E. C. GEHRUNG, M. D., OF ST. LOUIS, 

In acute cystitis, and in acute exacerbations of chronic cystitis, 
this practitioner (St. Louis Courier of Medicine, August, 1879,) 



CYSTITIS. 279 

has derived extraordinary advantage from elevating and fixing 
the bladder by means of filling the vagina with a cotton tampon. 
He uses dry cotton batting. He first surrounds the uterine neck 
with a few small wads of this substance. This is followed by a 
large wad or two, thoroughly compressed between the fingers to 
facilitate the introduction into the vagina, where, when let loose, 
it will enlarge by its inherent elasticity and fill this cavity. 
Thus, after careful adjustment of these wads, the bladder will be 
elevated and compressed against the pubes and abdominal walls, 
so to speak, between two elastic media. 

The patient expresses herself as decidedly relieved, and can at 
once rise to her feet and feel comfortable. The tampon should 
be removed and re-applied twice or thrice in the twenty-four 
hours. 

S. F. GILBERT, M. D., OF ELYSBTJRG, PENNSYLVANIA. 

In severe cases, the use of injections of tannic and salicylic 
acids into the bladder, is recommended by this writer. (Med. 
and Surg. Reporter, March 24th, 1879.) After washing out 
the bladder with warm water, several times, he throws in the 
following : 

269. R . Acidi tannici, gr. x. 

Acidi salicylici, gr. ij. 

Aquae, f-^iv. M. 

For an injection. Retaining it ten or fifteen minutes, then removing it and 
again washing the bladder out with warm water, to prevent the hardening of 
blood or mucus by the acids. 

GRAILY HEWITT, M. D., LONDON. 

The timely use of the bladder, after labor, will prevent that 
destructive cystitis, which may be produced by inability to evacu- 
ate the bladder. When it is present, with fever, pain, and ten- 
derness, leeches may be required. Demulcent liquids, as barley- 
water, should be used, and all irritants avoided. Best is exceed- 
ingly important. In the chronic form, it is best treated with 
diluted mineral acids ; uva ursi and jpareira brava are servicea- 



280 DISEASES OF VAGINA, URETHRA AND BLADDER. 

ble in combination with diluted nitro-muriatic acid. Sir Henry 
Thompson used a decoction of the triticum repens, in the male, 
with great good results, and Dr. Hewitt has found it of equal 
service in women. He has seen great benefit from counter-irri- 
tation just above the symphysis. The general treatment is im- 
portant. Some require liberal diet, others the reverse. 

PROF. ROBERT BARNES, M. D., LONDON. 

Diminish the irritating qualities of the urine; everything 
known to promote dyspepsia and lithiasis or oxaluria, must be 
avoided. Demulcents, then tonics, may be used. If lithiasis is 
present, use alkalies, as soda, potassa, or lithia. More com- 
monly, there is the phosphatic condition, with ammoniacal 
urine; here give mineral acids and tonics in moderate doses. 
Warm baths often afford great relief when there is great pain or 
spasm. 

(For a full discussion of the means of relief in cystitis, see 
Napheys' Surgical llierapeutics, 7th ed.) 



URETHRITIS. 281 

URETHRITIS. 

E. J. TILT, M. D., OF LONDON. 

When the difficulty or pain of micturition is not relieved by 
diluents, warm hip-baths, and poultices, urethritis may be sus- 
pected. In this case, the urethra can be felt with the finger to be 
round, solid, enlarged, and painful to the touch. Cooling injec- 
tions and mucilaginous drinks are called for, and if these do not 
answer, a tannin bougie should be introduced into the urethra 
three or four times, at five days' intervals. 

Tannin bougies are made by dipping medium-sized bougies 
into gum-water, powdering them with tannin, letting them dry, 
and after rubbing off the roughness, dipping them in gum- water 
previous to using them. 

In the event of these failing, a stick of nitrate of silver may 
be rapidly passed into the passage. 

DR. L. DE SINETY. 

This author, as previously observed (page 224), believes nearly 
all cures of urethritis in the female to be of specific origin. 
With other observers, he has found that the balsams have little 
influence on this disease in the female. Local baths and ure- 
thral injections of weak carbolic acid lotions will often suffice; 
in more rebellious cases, astringent injections of tannin, sulphate 
of zinc, or acetate of lead, or perhaps better, a solution of 
nitrate of silver, gr. j.-ij. to aquae f. Ij. If the disease resists, the 
surgeon may introduce into the whole length of the urethra a 
pencil of nitrate of silver, withdrawing it after a few seconds. 
This is a painful expedient, and may be followed by dysuria, 
but is effective. Another topical means is to introduce astrin- 
gent bougies, and let them dissolve in the urethra, as : 

270. R. Pulv. tragacanth., gj. 

Acidi tannici, . gr. xv. 
Bisruuthi subnitratis, q. s. M. 

For a urethral bougie 5 centimetres long. 



282 DISEASES OF VAGINA, URETHRA, AND BLADDEE. 
A. J. C. SKENE, M. D., BROOKLYN, N. Y. 

Diseases of the Urethral Glands. It has been pointed out by 
this gynecologist, (Proceedings of the Medical Society of the 
County of Kings , December, 1880,) that upon each side, near 
the floor of the female urethra, there are two tubules large 
enough to admit a No. 1 probe of the- French scale. They 
extend from the meatus urinarius upwards, from three-eighths 
to three-quarters of an inch, parallel with the long axis of the 
urethra. They are located beneath the mucous membrane in the 
muscular walls of the urethra. The mouths of these tubules 
are found upon the free surface of the mucous membrane of the 
urethra within the labia of the meatus urinarius ; they terminate 
in branched glands. 

These glands are subject to catarrh, gonorrhceal and strumous 
inflammation, and tuberculosis, giving rise to extreme tender- 
ness, painful micturition, great discomfort in sitting or walking, 
sometimes sharp pains and vaginismus and ulceration. 

The treatment required is to lay open the tubules throughout 
their whole length, and to keep them open. In the majority of 
cases, it is all that is required to effect a complete cure. The 
method of operating is as follows : The patient is placed upon 
the left side, and a Sims speculum used to keep the labia apart 
and retract the perineeum. This brings the parts well into view 
and within easy reach of the operator. 

The position and depth of the tubules having been first ascer- 
tained, the probe-pointed blade of a very fine scissors is then 
introduced, and the posterior wall divided its whole length. To 
prevent the parts from re-uniting, a small piece of cotton, satu- 
rated with 'persulphate of iron, should be packed in between the 
divided edges. Brushing the surfaces over with the iron, with- 
out using the cotton, will answer, although less certainly, to 
prevent re-uniting. Very little after-treatment is required. In 
the majority of cases, recovery follows the operation of laying 
open the canals. Sometimes the inflammation lingers in a modi- 
fied form, but yields to a few applications of nitrate of silver 



URETHRITIS. 283 

or sulphate of zinc. In several cases in which the excrescences 
were abundant, they remained after the operation, although very 
much reduced in size. An application of nitric acid destroyed 
them, and they have not shown the least disposition to return. 

A. W. SAXE, M. D., OF CALIFORNIA. 

This writer describes catarrhal as urethritis distinguished from 
gonorrhoeal inflammation, first, by the history of the case and 
moral probabilities ; second, by the absence of tenesmus in most 
cases of the gonorrhoeal variety; and third, by the absence of 
that profuse muco-purulent discharge which is inseparable from 
the early stages of the gonorrhoeal disease. 

It would be difficult to say what remedies have not been used 
in the treatment of this affection in its various stages and phases. 
The catalogue includes nux vomica, pareira brava, buchu, uva 
ursi, vaginal injections and suppositories, opiates, prussic acid, 
copaiba, and cubebs, and lately, the injection of normal urine 
into the bladder, etc., etc. (Pacific Med. and Surg. Journal, 
April, 1874.) 

His plan of treatment is as follows : 

1st. Horizontal position in bed indispensable. 

2d. Hot applications to the feet, with hot diluent drinks, so 
as to induce diaphoresis, if possible. 

3d. The administration, every two hours, of the following : 

271. R. Hydrarg. chlor. mitis, gr. xxxvj. 

Pulv. ipecac, gr. viij. M. 

Divide in chart. No. xij. Sig. — Dose one powder in a little syrup every 
two hours, until six are taken. Then follow with decoct, sennse, q. s., to in- 
duce action and free evacuation of the bowels. Diet very light and simple ; 
drinks, mucilaginous ; decoctions of elm bark or flaxseed are best, and are 
rendered palatable by the addition of a little orange peel, sugar, tartaric acid, 
or lemon juice. 

The only sedative or anodyne admissible is a cold, wet napkin 
to the vulva, changed sufficiently often to insure a low tempera- 



284 DISEASES OF VAGINA, URETHRA AND BLADDER. 

ture. Opiates are injurious. Chloral hydrate, gr. xv. to xx., 
at night, less objectionable, is seldom necessary. 

If, after the first twelve hours, and after the bowels have been 
freely evacuated, there is still much pain in passing the urine, or 
if there is any tenderness or tenesmus, the remaining powders 
should be given and followed by the laxative as before, after 
which it will be, in general, only necessary to keep the patient 
in bed for a few days, and to see that the bowels are kept open 
by neutral or alkaline salts every morning. This, with moder- 
ately improved diet and mucilages, will insure a perfect and 
speedy recovery. 

The pulverized ipecac, is a very important adjuvant to the 
alterative, but the quantity must be restricted to the tolerance of 
the stomach; a half grain will be sufficient in all delicate 
stomachs, and in many it will be too much. But whatever the 
stomach will tolerate without emesis, is the maximum. 

THOS. ADDIS EMMET, M. D., NEW YORK. 

Keep the patient recumbent, the bowels free by salines, and 
the urine bland. Use hot-water vaginal injections and warm 
sitz-baths. Also wash out the urethral tract several times a day 
with warm water. After washing out the urethra, the extract 
of pinus canadensis, to which a little impure carbolic acid has 
been added, should be thoroughly applied. Sometimes the ap- 
plication of a weak solution of nitrate of silver, or of impure 
carbolic acid, will be found useful. As the case improves, vase- 
line or a little tannin and glycerine will protect the parts suffi- 
ciently. 



TTBIXARY DISORDERS. 285 



URINARY DISORDERS-IRRITABLE BLADDER, DYSURIA 
POLYURIA, ISCHURIA, ETC. 

PROF. WM. GOODELL, M. D., PHILADELPHIA. 

In almost every form of vesical irritation, belladonna and its 
alkaloid, atropia, are valuable remedies. Dr. Goodell generally 
gives it according to the following prescription, which he can 
recommend : 

272. R. Atropine, _ gr.j. 

Acidi acetici, gtt. xx. 

Alcoholis, 

Aquse, aa f-^iv. M. 

Four drops before each meal in a wineglassfnl of water. To be increased 
or diminished according to the constitutional effect. 

In that form of irritability which consists in an inability to 
hold the water on slight exertion, such as coughing, laughing, 
running, etc., the cause is generally relaxation of the fibres. 
Ferruginous preparations are here demanded, and with them the 
best remedy is a combination of tincture of belladonna, tincture 
of mix vomica and fluid extract of ergot. If this fails, the next 
resort would be the application of carbolic or even nitric acid to 
the urethra, with proper hygienic treatment. 

A. J. C. SKENE, M. D., OF BROOKLYN.* 

Where the irritability is a pure neurosis, the general system 
demands most attention. Tonics, a well-ordered diet, change cf 
scene and cheerful company, are required. The bowels should 
be kept moderately open, and small doses of strychnia admin- 
istered. Locally, a cup of warm hop-tea containing twenty to 
forty drops of laudanum may be injected into the rectum, or an 

^Diseases of the Bladder and Urethra in Women, New York, 1878. 



286 DISEASES OF VAGINA, URETHRA AND BLADDER. 

opium suppository combined with belladonna or hyoscyamus ; 
or the following : 

273. R . Chloral hydratis, gr. xv. 

Aquae, f.^j--ij- M. 

For a rectal injection. 

Masturbation, malaria and hysteria, are occasional exciting 
causes of the complaint, and demand appropriate treatment. Ab- 
normal conditions of the urine are also frequent causes. In 
all cases the urine should be tested. If acid, alkalies are re- 
quired. In excessive acidity with deposits of uric acid, the 
following is a very efficient combination : 

274. R • Potassii bicarbonatis, 

Potassii citratis, aa % ss. 

Syrupi simplicis, % iv. M. 

Take a teaspoonful in half a tumbler of water, adding ^ j. of lemon juice 
Drink while effervescing. 

In oxaluria the following prescription is looked upon by many 
as almost a specific : 

275. R . Acidi nitro-muriatici diluti, 3 v ~vj. 

Tincturse nucis vomica?, £ iij. 

Olei gaultherise, "^ixij. 

Aquam, adf. t ^iij. M. 

A teaspoonful in water before each meal. Many of the slightly alkaline 
mineral-spring waters will also be found of use. 

DR. JOHN S. WARREN, OF NEW YORK. 

Dysuria is a common complaint among females, and may be 
owing to vascular growths about the urethral meatus, inflamma- 
tory affections of the urethra, anteflexion, etc. (N. Y. Medical 
Journal , 1878.) 

The growths are of all sizes and forms, varying from a slightly 
congested and hypertrophied condition of the mucous membrane 
of the canal to the size of a full-grown raspberry, to which, in- 
deed, it bears no small resemblance. It is generally situated at 



URINARY DISORDERS. 287 

the meatus externus, and, therefore, readily discoverable by an oc- 
ular examination after separation of the labia, though not infre- 
quently it is a little further distant within, and in such cases he 
has made use of the ordinary ear-specula for their detection and 
treatment. This tumor may be pedunculated or sessile in 
growth, is a bright scarlet color, easy to tear and bleed, and, as 
a rule, exquisitely tender and sensitive to the touch ; so that 
urination, coition, friction from clothing or from washing, give 
the most intense pain and suffering. 

The treatment for the removal of these painful growths is ex- 
cision by the scissors, cauterization by the actual cautery, nitric 
or carbolic acids, the silk ligature, and the snare — the one used 
for aural purposes is best adapted, and is especially used when 
the caruncle is situated some little distance from the meatus ; 
here, too, the ear-specula or glass tube is very useful for caustic 
application to the diseased portion of the urethra; for when the 
growth is sessile in character, its complete destruction by a 
powerful escharotic, like nitric acid, or the actual cautery, is 
necessary. 

DR. BRABAZON. 

Irritable Bladder. In this annoying complaint, this writer 
(Brit. Med. Jour., 1879,) has found the following injection of 
great service : 

276. B • Argenti nitratis, gr. ij. 

Extracti belladonna?, gr. vj. 

Aquae destill., f-^ij- M. 

For an injection. This solution should be injected twice a week, and al- 
lowed to remain in the bladder for about from three to five minutes, and then 
withdrawn through the canula. Several months may be necessary for a 
cure. 

Incontinence of urine is often best treated by forcible dilata- 
tions of the urethra, for which Weiss' female urethral dila- 
tory may be used. 



288 DISEASES OF VAGINA, URETHRA, AND BLADDER. 
DR. J. HALLIDAY CROOM, OF EDINBURGH, 

Sums up the causes leading to retention of urine in the female 
as follows : 

1. Injuries or contusions during labor, acting directly or by 
subsequent inflammations. 

2. Pressure of displacements or tumors acting mechanically on 
urethra or neck of bladder. 

3. Injuries or growths acting reflexly. 

4. Diseases of nervous system. 

5. Direct obstruction within the tube of the urethra, as from 
stricture or foreign bodies, such as a calculus. 

Previous to beginning treatment there are certain prelimina- 
ries to be observed, which may be stated thus : 

1. In all cases of retention of urine a vaginal examination is 
necessary. 

2. A gum-elastic male catheter of medium size, without the 
stilette, is the best form of instrument to employ. 

3. In retention from displacement it is important to remember 
the altered position of the urethra. In retroversion of the gravid 
uterus the vagina is drawn upward and forward, the meatus is 
drawn upward, and the direction of the upper part of the canal 
is backward and downward. 

4. When any difficulty exists in accounting for the retention 
a visual examination should be insisted on. 

5. It is a safe rule, before giving a definite verdict on any 
pelvi-abdominal tumor, to empty the bladder. 

PROF. THEODOR BILLROTH, OF VIENNA.* 

In many instances the treatment must have direct reference to 
the cause. This may be a flexion of the uterus, an irritating con- 
dition of the urine, exposure to cold and wet, injury in child- 
birth, etc. In every instance a thorough local exploration is 
required, palpation with the finger, and perhaps dilatation. 

*Handbuch der Frauenkrankheiten. 



URINARY DISORDERS. 2b 9 

The general measures required are tepid or warm sitz-baths, 
mucio-lainous injections and suppositories of cacao butter, with 
extract of belladonna, extract of hyoscyamus, or morphia. 
Bougies, medicated with extract of opium or morphia, may be 
placed directlv in the urethra, and to diminish the pain injec- 
tions may be thrown into the rectum, composed of linseed tea 
and laudanum, two oz. of the former to twenty drops of the latter, 
or a two per cent, solution of chloral hydrate. Acid urine will 
require free alkaline drinks, and for the general nervous phe- 
nomena small doses of lupulin, frequently repeated, or of canna- 
bis indica, are required. 

DR. F. WINCKEL, OF DRESDEN.* 

Paresis of the Bladder. This author observes that inconti- 
nence frequently results from paresis or partial paralysis of the 
bladder. It can frequently be avoided in women, especially that 
form of it which occurs in pregnancy, by the regular use of the 
catheter. When, however, this condition is actually present, the 
mos: important indication, in addition to the regular use of the 
catheter, say every four hours, is the application of electricity. 
This frequently gives admirable results in a few sittings. The 
induction current is used, and the one pole is inserted into the 
bladder, while the other is placed upon the symphysis or sacrum. 
The sittings are repeated daily, lasting about five minutes. 

Sometimes abundant irrigations of salicylizated water (1 to 1200,) 
repeated every few hours, will be sufficient to dispel a vesical par- 
esis. Nourishing diet, good wine — especially champagne — and 
white beer, are desirable. In simple atonic conditions camphor, 
and small doses of tincture of cantharides, from five to twenty 
drops, one to three times a day, may be cautiously employed, 
often with advantage. 

In that variety of retention of urine, which arises from neglect 
of emptying the bladder through modesty or from exposure to 
cold, ergot has rendered excellent service. The best form ap- 



*Handbuch der Frauenkrankheiten, edited by Billroth. 



19 



290 DISEASES OF VAGINA, URETHRA AND BLADDER. 

pears to be the fresh powder, from ten to fifteen grains, four to five 
times a day. It is also efficient taken in doses as high as 3 j. 
daily, in paralysis of the bladder, the result of cerebral apoplexy. 
Strychnia may also be employed in such cases. 

For the nocturnal form of enuresis, we have two so-called spe- 
cifics. One of these, hydrate of chloral, has been carefully em- 
ployed by our author, without obtaining any permanent good 
effects. Belladonna, in extract or tincture, offers greater prob- 
abilities; but the most efficient is a moderate dose of an opiate 
on going to bed. 



PROF. F. WINCKEL, DRESDEN.* 



Neuralgia of the Bladder. Cystospasm. This affection may 
follow mental excitement, onanism, catching cold at the men- 
strual period, indulgence in sour beer or wines, etc. There 
is no local disorder visible, and the condition of the urine is 
normal. The cramp is frequently obstinate, but usually yields 
to treatment in the end. 

Having paid due attention to diet and drinks, to clothing and 
habits, further reliance must be placed upon local anodynes. 
These may consist in a subcutaneous injection of morphia, in 
rectal injections containing opium, or in suppositories of cacao 
butter, medicated with morphia or belladonna. Internally, one 
of the best remedies is chloral-hydrate, which may also be used 
in rectal injections of 15 grains in J oz. of water. Another ex- 
cellent internal remedy is tincture of cannabis indica, of which 
10 or 15 drops may be used ten or fifteen times a day. 

When the above treatment fails of good results the patient 
should take warm baths daily, and drink freely of alkaline car- 
bonated waters. Such cases often demand mechanical treatment. 
This will consist in dilatation of the urethra as recommended by 
Dr. Hervetson, of London, who thus cured a case of fifteen 
years' duration ; or else by inserting into the vagina a broad and 

* Handbuch der Frauenkrankheiten. Edited by Billroth. 



URINARY DISORDERS. 291 

soft pessary to exert a moderate pressure on the bladder; or 
finally injections of morphia into the bladder followed by cau- 
terization. 

DR. ROBRET NEWMAN. 

Urethrocele. It is maintained by this writer (Amer. Jour, of 
Obstetrics, July, 1880,) that an operation is not always necessary 
to cure a urethrocele. The medical treatment which he success- 
fully employs is briefly described : 

The object is to restore the dilated part of the urethra to its 
normal calibre and subdue all irritating causes and inflamma- 
tions. Internal remedies must be given according to symptoms, 
as antiphlogistics to counteract inflammations, narcotics to allay 
pain and tenesmus, also to procure rest and sleep ; to these may 
be added emollients and antispasmodics. But our principal 
reliance consists in local measures, and some of these may even 
replace the internal remedies ; thus narcotics and others may be 
given in suppositories, subcutaneous and other injections. Hot 
applications externally. The bladder and urethra must be 
washed out as often as necessary with hot water, sometimes medi- 
cated, as required by symptoms. 

This cleaning, and freeing the parts from ail foreign bodies, 
does a great deal of good. The urethrocele proper must be ex- 
amined by ocular inspection with a short endoscopic tube. 
Through this tube local applications are made to erosions, ulcer- 
ations, and granulations only. This is done by a small brush, 
with stimulating or astringent remedies, as indicated. Strong 
solutions must be handled carefully, so that no healthy portion 
of mucous lining is touched. If a larger surface of mucous 
membrane is reddened or hypertrophied, he has made applica- 
tions with the atomizer through the same short endoscopic tubes, 
sometimes even with the atomizer direct. 

It is his conviction that most cases will get well under such 
treatment, if the patient is kept at rest with proper diet, careful 
attention, and skillful manipulations with trained assistants. Still 
more, he has seen a case recover under such treatment, after sev- 
eral plastic operations had utterly failed. 



292 DISEASES OF VAGINA, TJKETHREA AND BLADDEE. 

It is remarked by Dr. L. S. Oppenheimer, (Louisville Med. 
News, June, 1880,) that irritable bladder frequently arises from 
urethritis, specific or ^non-specific. In such cases he has found 
very rapid improvement follow the application of this solution : 

277. R. Chloral hydrate, 

Carbolic acid. 

Potassium iodide, aa ' gr. j. 

Water, ]f j. M. 

This is carefully and thoroughly applied by means of a small piece of 
absorbent cotton. The slight burning sensation caused by the application 
soon disappears. 

Iodoform suppositories are also of great value in various forms 
of urethritis. The following directions for preparing them are 
given by Dr. C. N. Fowler, in the Ohio Med. and Surg. Review, 
September, 1880 : 

278. R 



Iodoform, 


u: 


Isinglass, 


^iv. 


Gum tragacanth, (powd.,) 


£j; 


Glycerine, 


3 1 )- 


Water (to dissolve ingredients,) 


q. s. 



M. 

When sufficiently soft the mass is to be lolled into a cylinder small enough 
to be introduced into these canals and cut into pieces two inches in length. 
They can be introduced into the urethra of both male and female without the 
slightest difficulty. 

Another effective local anaesthetic is the bromide of potassium, 
injected, in solution, into the urethra. This has been strongly 
recommended by Dr. J. Kijanizyn. (St. Peterburger Med. 
Wochenschrift, No. 57, 1879.) It may also be used in the form 
of a suppository. 

[For the treatment of cystitis, incontinence of urine, irritable bladder and 
allied conditions, see Napheys' Surgical Therapeutics, chap. XL] 



i=^i3T ii. 



OBSTETRICAL 



THERAPEUTICS. 



INTRODUCTORY. 



CASE-TAKING IN MIDWIFERY. 



A plan for recording midwifery cases was carefully compiled 
by Prof. Alexander Russell Simpson, M. D., of Edinburgh, 
and published in the Edinburgh Medical Journal, February, 1881. 
Although prepared more especially for hospitals, it can, with 
appropriate omissions, be employed in private practice, and henoe 
we give it in this place : 

I. Anamnesis. 



Name para. 

Married. Single. Widow. Residence 

Menstruation began at Type days. Duration 

Date of last Menstruation from to 

Stir rage first felt Probable date of Conception 

Condition during Pregnancy — 

Complications of Pregnancy — 

Previous Obstetric History — 

II. Physical Examination on 

General Appearance 
Breasts 

"Inspection 
Mensuration 
Abdominal Walls 
" Cavity 



Age 
days. Quantity 



l«5 

w 

g 
o 

Q 
fa 
< 



Palpation 



Auscultation 



■5 



Height of Fundus 
Direction 
Size 
Form 
Head 
Back 
Limbs 

Uterine Bruit 
Foetal Heart 
Other Sounds 
295 



296 



OBSTETRICAL THERAPEUTICS. 



External Pudenda 
Vagina 
| <{ Cervix and Orifices 
Foetus 
Rectum and Bladder 

Pelvis/ 11 Cr I1, S P 

\ Ext. Conj Diag. Conj... 

Diagnosis of Presentation 

u Position 



< h 
3 

> Ph 



Inter-trochant 
True Conj 



D • f Date of Labor 

Prognosis < ^, 

& [ Character 



III. Labor on 



Pains began 

Os fully dilated at 

Presentation 

Position 

Mechanism — 

Duration of Stage I. 

Artificial Interference- 

Peculiarities — 
Condition 
Development 
Sex 



O 



Their character 

Waters escaped at 



II. 



III. 



Length 



Weight 



a ) 



Diameter 
m ] Circum- 
^ ference 

Placenta — Form 
Membranes 
Cord — Insertion 



0. M. 


O.F. 


S.O.B. 


Bi.-P. 


Bi.-T.iT.B. 


Caput sue. 











| 


Markings 









Size Weight 

Liquor Amnii 

Length , 

Convolutions round Ch Contortions , 



IY. Puerperium. 

, as on Special Sheet 



CASE-TAKING IX MIDWIFERY. 297 

V. Condition on Dismissal on * 69 o* 

f GeDeral 
Breasts 

rsize 

Uterus < Position 
tOs 

Vagina 

Pudenda 

Other Pelvic Tissues 
A ( General 
d «/ Mode of Nutrition 
£3 (, Umbilicus 

The first page begins with an indication of the nature of the 
case recorded on it, according to the class of labor to which it 
belongs, according to the following classification of labor : 

I. Natural Labor. — Head alone presenting, and the labor 
terminated within twenty-four hours. 

II. Lingering Labor. — Head presenting, but labor delayed 
beyond twenty-four hours. 

III. Instrumental Labor. — The labor needing to be ter- 
minated by some operation — 

1. Safe to mother and child — as forceps. 

2. Dangerous to child — as embryulcia. 

3. " mother — as Csesarean section. 

IV. Preternatural Labor, including — 

1. Pelvic presentations. 

2. Transverse " 

V. Complex Labors, presenting complications — 

A. On the part of the mother — as, 

1. Hemorrhage. 

2. Rupture. 

3. Convulsions. 

4. Thoracic and abdominal diseases. 

5. Inversion of the uterus. 

B. On the part of the child — as, 

1. Prolapsus funis. 

2. Twins. 

3. Monsters. 



CHAPTER I. 



THE DISORDERS OF PREGNANCY. 

The Hygiene of the Puerperal State — Abortion and Premature 
Labor {Prevention and Induction) — Vomiting and Nausea of 
Pregnancy — Sympathetic Nervous Disorders (Palpitation, Syn- 
cope, Neuralgia, Pruritus, Cutaneous Affections, etc.) — Digest- 
ive Derangements of Pregnancy (Dyspepsia, Constipation, 
Diarrhoea, Hemorrhoids, Icterus Gravidarum, Albuminuria.) 

HYGIENE OF THE PUERPERAL STATE. 

In order that the child-bearing woman may be enabled to 
give birth to a healthy offspring, that the act of delivery may 
be accomplished with safety to both mother and child, and that 
her subsequent getting up may not be impeded by debility, etc., 
it is absolutely imperative that, from the inception of pregnancy, 
she should be placed under the best hygienic surroundings. She 
requires an abundance of pure air, sunlight, moderate and care- 
ful exercise in the open air, plenty of nourishing and easily- 
digested food. 

Cleanliness must never be neglected ; tepid baths are always 
beneficial. 

While sedentary habits are always detrimental, great exertions, 
as dancing, horse-riding, or rough carriage-riding, must be equally 
avoided. 

There is no need of a special diet ; she requires to continue 
her usual food, merely eschewing anything hard to digest, or 
particularly stimulating. The pecular cravings incident to preg- 
nancy may be indulged in moderation, unless they are for arti- 
cles of a hurtful or doubtful character. Nor is it requisite to 

299 



300 DISORDERS OF PREGNANCY. 

medicate her, save for the correction of abnormal conditions, as 
constipation, acid stomach, vomiting, etc. 

Tight lacing, or clothing too tight in any way, will not fail to 
prove injurious. 

In short, let her take the same precautions in the care of her 
health that she would take under all circumstances. Mental 
excitement in every form should be sedulously avoided, and she 
should be carefully surrounded by everything calculated to main- 
tain a tranquil, happy disposition. 

To prevent depressed nipples, or any other condition of the 
mammae likely to interfere with the proper performance of their 
functions, these parts must be protected from pressure by tight 
clothing, or cold from an insufficiency of covering. 

Upon this subject we shall speak at length in the proper order. 

GEORGE H. NAPHEYS, M. D., OF PHILADELPHIA. 

This author, in his very excellent popular work on the hygiene 
of women, entitled The Physical Life of Woman, has collected 
together many valuable suggestions as to the care of the health 
of pregnant women ; and when such a work is desired by mar- 
ried persons for their instruction, none better can be recom- 
mended. His recommendations, briefly, are with reference to — 

Food. This should be varied, light and nutritious, with a 
special regard to the idiosyncrasies of the person, which, it 
should be noted, are often quite different in pregnancy from the 
ordinary state. After the sixth month, an additional meal each 
day should be taken, so that the system can meet the unusual 
demands upon it for nourishment without overloading the 
stomach. 

Clothing. This should be loose ; the attempt at concealment 
by tight dresses, so often made by young mothers, being especi- 
ally avoided. Flannel drawers should be worn when the preg- 
nancy is advanced. Pressure upon the lower limbs in the 
vicinity of the knee or the ankle joint should be avoided, more 
particularly during the last months. It is apt to produce 



HYGIENE OF THE PUEEPERAL STATE. 301 

enlargement of the veins, and finally varicose ulcers. The 
garters should not be tightly drawn, nor the gaiters too closely 
fitted, while yet they should firmly support the ankle. 

Exercise. Dancing, lifting, carrying heavy weights, and simi- 
lar forms of exercise, should be avoided. The same is true of 
horse-back exercise and driving over rough roads. Journeys 
should be taken as little as possible. The vibrating motion and 
sudden jars incident to railroad traveling often produce nausea 
and faintness ; sea-sickness, with its violent vomiting, not infre- 
quently leads to premature labor. Frequent short walks are the 
best form of exercise. 

Sleep. A larger amount of sleep than usual is demanded in 
the pregnant condition. Women should then lie abed late, and 
retire early, and a nap during the day is to be recommended. 
Late in pregnancy some women experience a sense of suffoca- 
tion on lying down. They should sleep on a bed-chair, or 
propped up on pillows. 

Mental Condition. Severe study, anxiety, and all exciting 
emotions and absorbing intellectual pursuits, should be sus- 
pended during pregnancy. The usual wide variations in the 
mental state, the feeling of despondency and that of exhilaration, 
should both be tempered by judicious representations of the 
groundlessness of the one and the risk of the other. The senses 
should not be over-stimulated by rank odors, loud noises, or ex- 
.tremely sapid condiments. 

Marital Relations. In the earlier months of pregnancy these 
may be moderately continued, except about the periods when 
the woman, if not pregnant, would have had her menses. In 
such cases the molimen is present, and coition tends to increase 
it and lead to abortion. In the last three months of pregnancy 
it is generally wiser to abstain wholly from sexual approaches. 



302 DISORDERS OF PREGNANCY. 

ABORTION AND PREMATURE LABOR. 

DR. ANGUS MACDONALD, OF EDINBURGH. 

This authority, in a discussion on the subject, (Edinburgh 
Med. Journal, 1880,) divides the treatment of abortion as fol- 
lows : 

1. Treatment of Threatened Abortion. The indication is here 
to arrest the uterine contractions and hemorrhage by rest, recum- 
bency, cool regimen and opiates. Search should be made for 
hydatids, as myxoma of the chorion is a frequent cause of abor- 
tion, and in such cases we ought not to attempt retention of the 
ovum. 

2. Treatment of Inevitable Abortion. If the bleeding is moder- 
ate and the contractions tolerably powerful, it is a mistake to 
consider that any specially active treatment is required, as the 
great majority of cases need nothing further than the free admin- 
istration of ergot, the maintenance of rest, quiet and recumbency, 
with cool, non-stimulating diet and careful regimen. Care ought 
to be taken to retain for the inspection of the doctor every bulky 
thing that is discharged, so that he may judge as to whether the 
entire ovum has beer* expelled or not. In such cases all that 
will be needed is possibly slight acceleration of the final stage of 
the abortion by gentle traction upon its presenting point after it 
is well into or through the os uteri, combined with pressure 
upon the fundus uteri by the hand on the abdomen. Still, even 
such easy cases require careful watching, because the hemorrhage 
is apt to be serious, and the ovum, if slow to separate, is liable 
to become putrescent. 

Dr. M. objects to the wholesale practice of what is called plug- 
ging the vagina, which is practiced almost universally in such 
circumstances. Plugging the vagina may be so conducted as to ar- 
rest the most severe uterine hemorrhage, but in that case the vagina 
must be carefully packed with the material used as a plug, every 



ABORTION AND PEEMATURE LABOR. 303 

corner of it being tightly filled. But what he objects to is plug- 
ging as it is ordinarily practiced. 

His opinion is, that in the ordinary run of cases, in which the 
hemorrhage is not specially profuse, we ought to trust to ergot by 
the mouth, or to ergotine subcutaneously, and that we shall most 
probably find all will go on right, except that we shall have to 
hurry the conclusion of the case with slight manipulation, and 
that wholesale imperfect plugging of the vagina is to be strongly 
deprecated. If, however, hemorrhage is severe, then active 
measures must be taken to empty the uterus. 

If the cavity of the cervix is sufficiently dijated so as to permit 
its being traversed by the index-finger, then by chloroforming 
the patient and introducing the one hand into the vagina, while 
with the other you depress well the uterus, it is usually possible 
to explore in detail every portion of the inner surface of a uterus 
at the third month, to make out whether the ovum is entirely or 
partially separated from it, and to break up any adhesions that 
may exist between the ovum and the uterus. Then, after the 
ovum is completely isolated from the uterine walls, a very mod- 
erate amount of pressure upon the fundus is sufficient to expel 
enough of the ovum through the open cervix to allow of its 
lower pole being gently grasped between the index and middle 
finger of the hand in the vagina, and in that way removed. 

At one time he used forceps for the removal of abortions, and 
many such are made. But forceps are liable to catch the uterine 
wall, and his conviction is that the best abortion forceps is the 
human fingers; and they have at least one advantage over every 
other instrument, that one can never forget them or leave them 
behind. 

In the meantime, it is advisable to have the patient well under 
the influence of ergot, whether the drug is administered by mouth, 
subcutaneously, or per rectum. If the abortion has been long on 
the way, it is advisable to wash out the interior of the empty 
uterus with a two per cent, solution of carbolic acid, and then 
make the patient comfortable and let her rest. Suppose, how- 
ever, as frequently happens, the cervix is not sufficiently dilated 



304 DISORDERS OF PREGXANCY. 1 

to allow the index finger to pass it, and the bleeding is serious. 
These are the classes of cases that one usually meets with as exam- 
ples of imperfect and useless plugging of the vagina. If the 
practitioner is able to stay with his patient, no objection can be 
made to plugging the cervix by means of a pledget of lint, ex- 
cept that it is only partially effective as a haemostatic, is some- 
what difficult to insert, and liable to be soon expelled. 

But the method of all others, the safest, speediest, and most 
agreeable, is to introduce a sponge-tent into the cervix, and leave 
it there from two to four hours. During an abortion a tent is 
never difficult to introduce, as there is almost always a consider- 
able amount of dilatation at the inner os, so that a moderately 
large tent may be passed with ease. Besides this, the resistance 
to dilatation in the neck of the uterus is not specially great, so 
that the tent rapidly expands, and will be found fully dilated in 
three or four hours at most, and thus septic changes are not 
likely to be set up by the tent. The gradual distension of the 
tent acts as an efficient plug against hemorrhage. At the same 
time, the stimulus of the dilating tent reflexly operates upon the 
uterus, promoting contraction of it. In this way the abortion is 
hurried to its close. 

In certain cases in which the great bulk of the ovum has been 
expelled, and from examination of the discharge you are not 
satisfied that the whole has come away, and yet you find the 
cervix is not sufficiently dilated to allow a finger to pass it, the 
use of a copper curette will be sufficient for all the requirements 
of the case. After its use the uterus ought to be washed out by 
means of a double catheter with a two per cent, solution of car- 
bolic acid. 

3. After- Treatment of Abortion. So soon as the uterus is per- 
fectly emptied, and, if thought necessary, disinfected by being 
washed out with a suitable solution of carbolic acid, the patient 
should be kepi in bed for a iveelc, at least. The harm that is done 
by getting up too soon after abortion is incalculable. It is a 
common proverb that "it is better to have a broken leg than a 
bad sprain." There is no doubt that it is frequently better for 



ABORTION AND PREMATURE LABOR. 305 

a woman to undergo a severe labor than an abortion. The rea- 
sons are similar in both eases. 

As the risks from septicemia in connection with abortion are 
considerable, and the more so if the ovum has, from whatever 
reason, become putrid before its expulsion, or even if the abor- 
tion has been long in the way, the greatest care ought always to 
be employed, by the use of antiseptic vaginal, and, if need be, 
uterine washes, to avoid absorption of putrescent materials. The 
maintenance of efficient contraction in the uterus is also a con- 
siderable safeguard against absorption of such materials through 
the venous channels, at least, and this should be aimed at by the 
diligent use of ergot. The results of ergot upon a small uterus, 
with its muscular wall only imperfectly developed, are, of course, 
less to be trusted to than in dealing with a uterus at term, when 
the muscular wall is powerful, so that we ought to depend most 
on cleanliness and antiseptics. 

4. Treatment of Sequelae of Abortion. — The most prominent 
of these is menorrhagia with consequent ansemia. 

In some of these cases the placenta, or portion of the decidua 
left adherent in the interior of the uterus, has undergone a low 
kind of organization, " has formed what in this country we call 
placental polypi." When these are present it is not uncommon 
to find considerable dilatation of the cervix persistent, so that its 
cavity, months after the abortion, is traversable to the examin- 
ing finger. But in other cases it would appear that mere relaxa- 
tion of the muscular wall of the uterus, and the presence of a 
congested, probably granular condition of the mucous membrane, 
is all of a pathological nature that can be found. 

In the first class of cases the uterus may be emptied without 
any antecedent dilatation process. The polypi are to be broken 
off by the finger, or scraped off with a blunt copper curette; 
the uterus then washed out with solution of carbolic acid ; and 
possibly, with rest and ergot, all will go well. The solution of 
the pernitrate of iron is doubly useful in suck cases as an internal 
medicine; it meets the requirements of the system for iron, 
while it acts at the same time as a powerful haemostatic. 

20 



306 DISOEDEES OF PREGNANCY. 

Id those cases in which the cavity of the cervix is tightly 
closed, the most efficient means of treatment is the use of a 
tangle or sponge-tent. Before the use of the curette became so 
general, many were in the habit of dilating such cases, and 
although finding nothing in the uterus to remove, almost always 
observed that the hemorrhage ceased. The possible explanation 
was that the irritation of the tent stimulated the flabby uterus, 
made it firmer, and less inclined to bleed. 

It very often results that after such dilatation, when you SGrape 
the whole of the interior of the uterus with a copper curette, 
you find that nothing will come away. On other occasions you 
find that soft, thickened fungous patches of hypertrophied 
mucous membrane peel off freely from a particular portion or 
portions of the area of the body of the uterus. There is no 
doubt but the removal of them is necessary to the restoration of 
healthy action of the mucous membrane of the body of the 
uterus. 

Hence, in general term, in the treatment of severe and ex- 
hausting hemorrhage, continuing for months after an abortion, 
the proper treatment is to dilate the cervix with a tangle-tent, 
and explore the cavity of the uterus, unless the cervix is so open 
as to allow exploration of the cavity of the body without dila- 
tation. If, then, any considerable portion of lowly organized 
remains of the abortion are present, they may be removed with 
the finger-nail. If, however, there is only present an irregular 
soft condition of the mucous membrane, then the surface ought 
to be scraped with a copper curette. 

DR. THEOPHILUS PARVIN, OF INDIANA. 

Dr. Parvin, writing upon the treatment of abortion, states 
his belief that ergot is a hindrance rather than a help in securing 
complete evacuation of the uterus in early abortions. The tam- 
pon, however, especially if introduced into the cervical canal, 
assists to procure dilatation, and, while restraining the loss of 
blood, causes what little escape of blood takes place above it to 



ABORTION AND PREMATURE LABOR. 307 

aid in separating the ovum from its attachments to the uterus. 
So long as the ovum is entire (and its integrity should be scru- 
pulously preserved,) we may hope for its complete expulsion, 
and should usually abstain from active interference. When the 
sac is broken, we should empty the uterus artificially, if, after 
removing a tampon that has been applied a few hours, the 
hemorrhage is at all profuse and the ovum is not expelled at 
once. This should be done with the finger ; and, instead of 
drawing the uterus down within reach of one finger, as recom- 
mended by Simpson, of Edinburgh, it is better to follow the 
practice of Mauriceau — introduce the hand into the vagina 
(under anaesthesia,) and use two fingers within the uterus, " as 
crabs do when they grip anything with one of their forked 
claws." 

When immediate evacuation of the uterus is demanded, on 
account of dangerous hemorrhage or an offensive discharge, an- 
nouncing the possibility of septicaemia, there is a still better 
way to proceed : " Let the patient lie on her baek upon a hard 
bed, her hips brought to its edge, lower limbs strongly flexed ; 
then introduce Neugebauer's speculum, and bring the os fairly in 
view ; now catch the anterior lip with a simple tenaculum, or bet- 
ter, with Nott's tenaculum-forceps, and then, if there be any flexion 
— and it is not uncommon in cases of spontaneous abortion to 
observe this — use gentle traction to straighten the bent canal ; 
at any rate, fix the uterus by the instrument. ISTow, take a pair 
of curved polypus-forceps of suitable size, or, better still, Em- 
met's curette-forceps, and gently introduce the closed blades into 
the uterine cavity, open them slightly, then close them and with- 
draw, when the fragments of membranes can be removed, and 
the instrument re-introduced. Repeat this three or four times if 
necessary." The uterus should then be swabbed out with 
Churchill's tincture of iodine by means of an applicator. 
Finally, ten or fifteen grains of quinine should be given, and it 
will be very rarely indeed that convalescence will not be prompt 
and perfect. 



308 DISORDERS OF PREGNANCY. 

PROF. W. S. PLAYFAIR, M. D., EDINBURGH. 

This author believes that we may hope to prevent an abortion 
if there is no dilatation of the os and the hemorrhage has not 
been excessive. But if the os be open, the finger can touch the 
ovum and pains are present, the indication is that the ovum must 
be expelled. Place the patient in bed, keep her cool, give her 
light diet. She should not rise for any purpose. To avert 
uterine contractions, no remedy is so useful as opium, given 
freely and repeatedly, either in the form of the tincture or of 
Batt ley's sedative solution, say 20 to 30 minims, repeated in a 
few hours. Chlorodyne is still better, in doses of 15 minims 
every third or fourth hour. If advisable, as from irritability of 
the stomach, this may be given in starch by the rectum. The 
patient should be kept under the influence of the remedies for 
several days, until all symptoms have disappeared; at the same 
time avoid constipation, itself a source of irritation, by small 
doses of castor oil, or other gentle aperients. 

Dr. R. P. Harris, American editor of Dr. Playfair's work, 
speaks emphatically of the value of opium in these cases. 

As a prophylactic of the tendency to abortion, remove the 
causes when known, as a syphilitic taint and constitutional 
debility. Retroflexion of the uterus may be relieved by a pes- 
sary, until the uterus has risen out of the pelvis. 

Syphilitic infection should always be inquired for, where fre- 
quent abortions occur, and both husband and wife should be 
placed under anti-syphilitic remedies. Diday insists that at 
each impregnation the mother should be thus treated, even 
though she exhibit no traces of the disease. Thus we may hope 
that infection of the ovum may be prevented. 

In fatty degeneration of the chorion, villi and other morbid 
states of the placenta, preventing proper nutrition of the foetu«, 
nothing can be done save to improve the mother's health. 
Simpson recommends chlorate of jiotassa when the child habit- 
ually dies in the latter months of pregnancy, with the idea of 
supplying oxygen to the blood. The theory is doubtful, though 



ABORTION AXD PREMATURE LABOR. 309 

the drag may act well as a tonic. It may be given in doses of 
15 to 20 grains, three times a day, and advantageously combined 
with dilute hydrochloric acid. 

Where no appreciable cause can be discovered, prolonged rest, 
at least until the time has passed at which abortion usually has 
occurred, will give the best chance for its avoidance. Care will 
be necessarv lest the health suffer from want of fresh air and 
exercise. The rest should be extremely strict at the menstrual 
periods ; in the intervals, she may lie on a sofa and spend part 
of the time in the open air. Sexual intercourse should be pro- 
hibited. 

When abortiou i.-s inevitable, we must favor the expulsion of 
the ovum. When the os is dilated, the pains strong, the ovum 
separated and protruding, depress the uterus from above by the 
left hand, and scoop out the ovum with the examining finger. 
If beyond reach, administer chloroform, pass the entire hand 
9 into the vagina, and the finger into the uterus. This is safer 
and more sure than the use of any form of ovum-forceps. 
When this fails, or the os is not dilated, plug the vagina. The 
best plan is with pledgets of cotton- wool soaked in water. Each 
should be snaked also in glycerine to prevent the offensive odor 
which otherwise will arise. In six or eight hours remove the 
plug and insert a fresh one if requisite. Two or three full doses 
of liquid extract of ergot f. 3 ss.-f. 3j. each, or a subcutaneous 
injection of ergotine, may be given. These two excitants of 
uterine action, the plug and the ergot, often effect complete de- 
tachment, and the ovum is readily removed when the plug is 
withdrawn. When dilatation does not readily occur, it may be 
aided by tents, especially the sponge, which also acts as an 
effectual plug. 

As long as the placenta or membranes are retained, septicemia 
is likely to occur, therefore it is important that they should be 
removed ; and in the event of delay, fcetor, and decomposition 
may be prevented by the use of intra-uterine injections of di- 
luted Condy's fluid ; not more than a drachm or two should be 



310 DISORDERS OF PREGNANCY. 

thrown in at once, and the os must be sufficiently patulous, or 
injury may result. 

A. J. C. SKENE, M. D., OF NEW YORK. 

This writer [Half-Yearly Compendium, July, 1876,) sums up 
the rules of practice in abortion as follows': 

1. Where the symptoms of abortion are slight, and of short 
duration, efforts should be made to arrest it. 

2. During dilatation of the os, opium should be given, if 
there is any call for it, and ergot should be carefully avoided. 

3. Hemorrhage should be controlled by tamponing the cervix, 
the hydrostatic dilator being the best for that purpose. 

4. When the os is fully dilated, and the ovum is not properly 
expelled after the use of ergot, it should be removed by the for- 
ceps and curette. 

5. Post-partum hemorrhage should be arrested by ergot and 
the intra-uterine tampon. 

The inflammation of the uterus, peritoneum, or cellular tissue, 
which may arise, should be treated on genera) principles. 

PROF. WM. LEISHMAN, M. D., GLASGOW. 

In some cases, it would seem as though the uterus had con- 
tracted a habit of abortion ; hence we must tide over this period, 
and thus break up the habit. 

The strictness of rest must be proportioned to the number of 
abortions; in obstinate cases, nothing but absolute confinement 
to bed will suffice. When irritations arise, liable to act reflexly 
on the uterus, these must be removed, as diarrhoea, skin or blad- 
der troubles, or even toothache. Caution the patient against 
tight lacing. When hemorrhage commences, rest on a hard 
mattress must be enjoined. The food should be non-stimulating, 
and meat sometimes is best avoided. Opium is the sheet-anchor. 
Chloral, by the mouth or rectum, has been employed with suc- 
cess. Until the fcetus is known to be dead 5 act as though it were 



ABORTION AND PREMATURE LABOR. 311 

living When, however, abortion is inevitable, as shown by dis- 
charge of the liquor amnii, profuse hemorrhage, and violent 
pains, in the first three months, the less we interfere the better, 
for experience shows that the ovum will generally escape entire, 
while manipulations may only serve to rupture the membranes, 
and thus cause retention of a part or the whole. Plug the 
vagina for hemorrhage, as suggested by Dewees, with a large 
sponge filled with vinegar. Astringents are sometimes given 
with good effect, as acetate of lead, gallic acid, and the mineral 
acids. In more advanced pregnancy, oxytocics come into use. 
A simple enema, or one containing turpentine will aid to excite 
uterine contractions. The placenta generally occasions the most 
difficulty. When this is retained, and the os closes, we must 
wait ; the finger cannot be introduced, and ergot is of no use. 
Symptoms must be met as they arise. When dilatation occurs, 
or severe flooding demands action, careful effort must be made 
to bring away any portion that may protrude. More reliance 
should be placed upon fingers than instruments. 

After an abortion, the health should be built up by tonics as 
demanded, and fatigue and exertions should be avoided for a 
while. 

ALFRED MEADOWS, M. D., OF LONDON". 

Ergot is exhibited by this author in habitual abortion depend- 
ent upon a weakened atonic condition of the uterus. {Practitioner, 
September, 1868.) He commences in small doses (TT^v.— viij. 
extracti ergotse liquoris, British Pharmacoepia,) as soon as preg- 
nancy is known to exist, and continues it in increasing doses 
(Tf[xx.-xxx.,) as long as it may seem necessary, certainly till 
after the period of the accustomed abortion, but with the occa- 
sional omission of a week or two. In unsuitable cases, this 
mode of treatment may be productive of mischief; for, as Dr. 
Meadows remarks, its employment is a matter of extreme deli- 
cacy, requiring a very careful discrimination of the cause of pre- 
vious abortions, and of the actual present condition of the uterus. 

On the general use of opium in abortion, it may be concluded, 



312 DISORDERS OF PREGNANCY. 

from the evidence offered, that it is of value in threatened abor- 
tion arising from accident, from mental causes, or from habit, 
when it may be given by the mouth, or in a cold starch injection 
thrown into the bowel, repeated every night, or oftener, accord- 
ing to circumstances; the application of cold, perfect quiet, and 
unstimulating diet, being at the same time enforced. When, 
however, abortion is threatened from foetal disease or imperfec- 
tion, so that the premature emptying of the uterus is but an 
effort of nature to get rid of that which she cannot accomplish, 
opium does harm, by retarding the emptying of the uterus, which 
must sooner or later take place. After abortion has taken place, 
opium allays excitement, tranquilizes the circulation, and pro- 
cures sleep. 

ROBERT BURXS, M. D., OF PHILADELPHIA 

Speaks highly of arsenic as a haemostatic, in doses of twenty 
minims of the liquor potassse arsenitis, at intervals of half an 
hour, until some decided effect is produced. 

When gestation has reached the fifth month, the membranes 
may be punctured to lessen the hemorrhage and facilitate expul- 
sion. It is better to leave a portion of the membrane, etc., than 
to employ forcible extraction, unless the discharge be excessive 
or offensive; then any fragments should be removed, and the 
vagina and uterus washed out with warm water. Generallv, 
when all is away, the hemorrhage at once ceases. Even a very 
small portion will serve to keep up the discharge, and this is a 
valuable point for diagnosis and treatment. Prophylaxis will 
consist in local depletion and saline purgation in blood stases; 
support and tonics for debility; quiet, especially at the- men- 
strual epochs; avoidance of sexual excitement, and sedatives 
when required. Chalybeate tonics are to be avoided, as encour- 
aging abortion, though in ansemia they are undoubtedly of great 
service. 

Tanner, and Laferld, of Malta, regard asafoetida as a 
uterine tonic in weak, irritable women, where there is an absence 



ABORTION AND PREMATURE LABOR. 313 

of vascular congestion ; ergot acts in this way, and may be given 
in doses of ten minims of the liquid extract every four, six or 
eiwht hours, and for two or three weeks at about the time when 
the abortion is expected from previous experience. In syphilitic 
taint, bichloride of mercury is invaluable. 

PROF. KARL SCHROEDER, M. D., OF BERLIN. 

To prevent the abortion, the woman should remain constantly 
in the dorsal position, and a few full doses of tincture of opium 
should be given by the mouth or rectum. When profuse hem- 
orrhage threatens the life of the mother, the tampon, mineral 
acids and ergot, internally, and vinegar and cold water to the 
abdomen. The caoutchouc tampon is objectionable, as it, when 
filled, only increases the tendency to dilatation of the os and 
uterine contractions. Lint pressed against the bleeding surface 
adheres and checks further flow; hence a small tampon will 
often suffice. Introduce the speculum, open it widely, and pack 
the lint entirely over the bleeding cervix, and then fill in behind 
this; withdraw the speculum while holding the plug closely in 
place with a long rod. At the end of six hours remove the tam- 
pon and re-apply it if necessary. The hemorrhage may thus be 
entirely checked, or the ovum may be found lying loose within 
the cavity. As this method does not increase uterine action, 
hope may be entertained, even yet, of saving the ovum. 

To remove the ovum, when necessary, Honing recommends 
the compression of the uterus by combined manipulation. Two 
fingers of the one hand are brought into the anterior vault of the 
vagina, and placed against the body of the uterus, while the 
other hand presses from outside upon its posterior wall. Or, the 
uterus may be pressed from outside against the symphysis. This 
method of expulsion succeeds easily and perfectly. 

After the hemorrhage is over, the patient is to be treated as a 
parturient woman. If the ovum was putrefied, or decomposing 
shreds are found, injections of tepid water or infusion of chamo- 
mile should be used thrice a day. 



314 DISORDERS OF PREGNANCY. 

J. G. SWAYXE, M. D., BRISTOL, ENGLAND. 

The following formulae are of service in cases of accidental 
hemorrhage during pregnancy : 



279. E . Acidi sulphurici diluti, 


£3J- 




Tincturse opii, 


TTlxl. 




Infusi rosae compositi, 


f-3vj. 


M. 


Two tablespoonfuls every other hour. 






280. R . Plumbi acetatis, 


gr. xviij 




Acidi acedci, 


TT\,XX. 




Morphia? acetatis, 


g r - J- 




Aqnse destillatse, 


f-3vj. 


M, 


Two tablespoonfuls every hour 







The woman is also, of coarse, to be kept in a recumbent posi- 
tion, and cold compresses applied to the abdomen and vulva. 
Cold drinks and cold-water enemata may be administered. By 
the employment of these expedients, the bleeding may be 
checked, and the patient carried in safety to the close of her 
pregnancy. 

PROF. FLEETWOOD CHURCHILL, M. D., DUBLIN. 

At an early stage, this author has repeatedly found the tinc- 
ture of Indian hemp, in doses of 5 or 6 drops every 2, 4 or 6 
hours, to check the hemorrhage. The usual remedies failing, 
and the abortion being inevitable, and the hemorrhage becoming 
alarming, he employs, for the removal of the ovum, an instru- 
ment consisting: of a steel rod divided into three claws at one ex- 
tremity, which expand widely when set free. This is enclosed 
in a small flexible catheter, and the claws are thus closed ; when 
retracted, the claws open. The ovum may thus be seized with- 
out danger to the uterus, and where it is impossible to introduce 
the hand. The introduction of the hand into the vagina and 
the fingers into the uterus is not free from danger. Dewees 
employed a wire crotchet to bring away the ovum, but the pla- 



ABORTION AND PREMATURE LABOR. 315 

cental forceps of Dr. Henry Bond, of Philadelphia, are perhaps 
the best for the purpose. 

In cases of great flooding, the plug becomes necessary, and 
where the ovum is still retained, half drachm doses of ergot may 
be given occasionally. 

INDUCTION OF PEEMATURE LABOR. 



G 



This writer (St. Bartholomew' 's Hospital Reports, 1875,) enumer- 
ates the following as the methods proposed for inducing prema- 
ture labor : . 

1. Evacuation of the liquor amnii by puncturing the rnem-jl 
branes. 

2. The administration of certain drugs, particularly ergot of 
rye. 

3. The injection of water into the vagina. 

4. The injection of water within the uterus. 

5. The injection of atmospheric air or carbonic acid within 
the uterus. 

6. Galvanism. 

7. Irritation of the mammae, by means of cupping-glasses. 

8. Separation of the membranes from the uterine wall, as far 
as is practicable, with the finger. 

9. Insertion of a long gnm-elastic catheter between the mem- 
branes and the wall of the uterus. 

10. Dilatation of the vagina by means of air-bags. 

11. Dilatation of the os uteri by air-bags. 

12. Dilatation of the os uteri by means of sponge-tents. 
Most of these are open to the objections that they are uncer- 
tain, or hazardous, or have unpleasant sequelae. 

Most of them are practiced in such a manner as to force on too 
hurriedly the uterine contractions ; and that which consists in 
the evacuation of the liquor amnii stands self-condemned, as de- 



316 DISORDERS OF PREGNANCY. 

priving the womb, at the very outset, of the all-important dila- 
tor provided by nature. 

Dr. (jr.'s mode of procedure consists in insinuating, night and 
morning, between the cervix uteri and the membranes, sponge- 
tents of gradually increasing size ; the first, and each succeeding 
one, being as large as the parts will admit. On removing each 
tent, and before replacing it by another, a warm douche, contain- 
ing Condy's fluid, is administered. He has found the use of one, 
two and three tents to be sufficient, and has never had occasion 
to employ more than four. 

The instrument by means of which the tent is placed in posi- 
tion was made for him in London. It is fully described in the 
Lancet, April 22d, 1871. 

It entirely obviates the use of the speculum, and being pro- 
vided with what is equivalent to a universal joint, it enables the 
tent to be pushed, without extraneous guidance, between the cer- 
vix and the membranes, taking of itself the readiest path pre- 
sented to it. For the same reason the membranes run no risk of 
puncture. The tents themselves are short, rounded at the 
extremity, and perforated, to facilitate adaptation to the instru- 
ment. 

The apparatus, and the mode of its application, are so simple, 
and so free from inconvenience and danger, that its use causes in 
practice little or no anxiety on the part of the patient; and until 
labor sets in, she moves about without pain or inconvenience, re- 
gardless of the presence of the tent. 

PROF. W. M. LEISHMAN, M. D., GLASGOW. 

The rupture of the membranes by means of a quill or in any 
other way, is a certain and effectual method, but open to serious 
objections. It compromises, very decidedly, the chances of the 
child, by allowing pressure upon it to the end of the labor. 
Again, if the os is imperfectly dilated, the membranes may be 
retained with a fatal result to the mother. 

Prof. Hamilton, of Edinburgh, recommends separation of 



ABORTION AND PREMATURE LABOR. 317 

the membranes by a finger or the sound passed within the os 
uteri. This may, however, be solely due to the forcible dilata- 
tion of the os, and which may be equally successfully done with 
tents. Most operators prefer, as sate and efficient, the introduc- 
tion of an elastic catheter within the uterus and outside of the 
membranes, up a distance of six or seven inches, and allowed to 
remain. Sooner or later, the uterus is stimulated to contract. 

An equally safe method is the use of Braun's colpeurynter, 
GariePs air pessary, or other form of plug. Vaginal or 
uterine injections are made by directing a constant stream of 
warm water upon the os by means of a long tube. Some 
allow a free egress for the water ; others endeavor to retain it so 
as to act in detaching the membranes. This is repeated once or 
twice a day, and generally brings on contraction after eight or 
ten applications. It is by no means free from risk, and full 
egress should always be allowed for the fluid. 

The intra-uterine douche is effective, though doubtful as to 
safety. 

The most recent method is that of Barnes ; dilatation of the 
os by means of graduated fluid pressure. He makes two stages — ■ 
provocative and accelerative. For the first he passes an elastic 
bougie six or seven inches into the uterus, coils up the remainder 
in the vagina, and lets it remain. Next morning there is gener- 
ally some uterine action; or it may be suffered to remain. Be- 
fore rupturing the membranes, adapt a binder to the abdomen 
tightly, so as to keep the head in close apposition to the cervix. 
This often prevents the cord being washed down. Dilate the 
cervix by the medium or large bag till it will admit three fin- 
gers ; rupture the membranes, introduce the dilator, ard expand 
till the passage is open for the child. If there is room, and 
there are pains, leave the rest to nature. Otherwise, use the ac- 
celerative method — the forceps or turning ; or, if the passage of 
a living child is hopeless, craniotomy. Twenty-four hours in 
all from the insertion of the bougie should see the termination. 
The fiddle-shaped bags are used as dilators. The middle is 



318 DISORDERS OF PREGNANCY 

grasped and held by the os so that they cannot slip either way. 
Their introduction is effected by means of the cup-shaped pouch 
in which the sound is inserted. First, empty out the air and 
turn the cock ; then fold the bag jn itself, and pass it with- 
in the os. The nozzle of a syringe filled with water is adapted 
to the tube, and the fluid cautiously injected After moderate 
dilatation the cock is closed and the bag left in place. Subse- 
quent dilatation should be gradual, and is an imitation of the 
effect of the liquor amnii in the membranes. Larger bags may 
be subsequently used, or two inserted at once. 

Galvanism is uncertain, and its use has been abandoned. 

PROF. KARL SCHEOEDER, M. D., BERLIN, 

thinks Krause's method, the introduction of an elastic catheter, 
is preferable. This is explained above. Generally this suffices, 
and labor sets in. Should delay occur, Cohen's method of in- 
jections between the ovum and uterus may be used. A catheter 
is passed well up, and tepid water injected till tension is felt. 
The membranes are thus detached, and uterine action is aroused. 
But this is more inconvenient, and very dangerous. 

Tarnier's method, by the " intra-uterine dilator," can never 
supersede the simple catheter. It is inconvenient, and not ap- 
plicable for general practice. 

Mechanical dilatation is recommended by Brunninghatjsen, 
Kllge and Barnes. -These dilators are difficult to introduce, 
and are of no advantage. Those of Barnes require a previous 
dilatation permeable by two fingers. 

Plugging the vagina as by Scholler, Htjter and Bratjn : 
the colpeurynter is slow and uncertain, inconvenient, and causes 
great pain. It may be useful where there is hemorrhage, or 
when the pains cease, to provoke them, or where there is also 
required a counter-pressure against the membranes which are 
about to burst. This the colpeurynter is sure to prevent. 

Kiwisch's ascending douche, at 30-35° R. against the os for 
10 to 15 minutes, is not reliable, nor free from danger, but may 



ABORTION AND PREMATURE LABOR. 319 

favor dilatation of a closed cervix, and prepare for the use of 
other means. 

Puncture of the membranes, as by Scheel, Hopkins and 
Meissner, is followed more slowly by the desired effect. Ro- 
kitansky, Jr., very highly recommends it. He considers that 
it gives better results to mother and child than any other method. 
Meissner used a long, curved trocar, to puncture the mem- 
branes high up. This is difficult, and now abandoned. 

ALFRED MEADOWS, M. D., LONDON, 

Adopts in preference the following plan : He secures free evacua- 
tion of the bowels, then introduces a sea-tangle tent, the size of a 
No. 7 catheter. The os is thus dilated so as to admit a small-sized 
rubber bag; in five or six hours this may be withdrawn and a 
larger one introduced, and so on till action is induced. Or an 
elastic bougie is passed into the uterus, so as not to rupture the 
membranes. The cervix is now generally the size of a five- 
shilling piece. Uterine action is set up, and goes on more or 
less speedily. 

PROF. W. S. PLAYFAIR, II. D., LONDON, 

Considers it always an advantage to allow the pains to come 
gradually, in imitation of natural labor; therefore, if after the 
bougie has been inserted, contraction come on strongly, the case 
may be left to nature. If feeble, resort to dilatation by means 
of the fluid bags, and subsequently puncture the membranes. 
In this way, the labor is completely under control, and he be- 
lieves this method will commend itself as the simplest and most 
certain mode yet known, and most closely imitating the natural 
process. 

PROF. FLEETWOOD CHURCHILL, M. D., DUBLIN. 
Abdominal frictions and manipulations with warm bad is, etc., 



320 DISORDERS OF PREGNANCY. 

rarely succeed. This author thinks the plan of KiwiSCH admi- 
rable. This is the throwing a stream of warm water upon the os 
by means of a long tube. * It rarely fails, and may be used for ten 
or fifteen minutes once or twice a day. The profession is now 
in possession of sufficient experience to pronounce favorably of 
this plan ; and it will probably supersede all others. 

The application of belladonna to the os uteri is doubtful and 
dangerous. 

Galvanism has been successfully employed by a number of 
practitioners. 

CHARLES CLAY, M. D., LONDON. 

This author, like many others, has no confidence in emmena- 
gogues, as they constantly fail, even when pushed to an enor- 
mous extent. The only certain means is the destruction of the 
vitality of the embryo, as it then becomes a foreign body. 
/^This is best effected by the use of the male catheter; the escape"} 
( of waters down the tube, with a tinge of blood, is evidence of/ 
1 success. 



Proposes to excite the womb by reflex action, by sucking and 
rubbing the breasts; these failing, he says Scheel's mode of 
perforating the membranes is the most sure, and rarely fails, 
but is objectionable because of the delay and the risk to the 
child, etc. 

He alludes to the gradual dilatation of the neck by sponge- 
tents and tampons in the vagina as inconvenient, painful and 
otherwise objectionable. 

He says, in review, the uterine douche of Kiwisch is prefer- 
able when prompt action is not obligatory, because of hemor- 
rhage, and the membranes can readily be perforated if danger is 
imminent, and thus the volume of the womb may be rapidly 
diminished. The injections into the cavity of the uterus by 
Cohen's method are difficult, especially in the primipara, where 



ABORTION AND PREMATURE LABOR. 321 

the neck is closed or displaced; and dangerous at least to the 
child, because of the liability to penetrate the membranes. 

PROF. S. TARNIER, PARIS, 

Prefers the separation of the membranes when (he internal orifice 
is open; dilatation of the neck when the orifice will not admit 
of the passage of instruments to separate the membranes. A 
last resource will be the excitation of reflex action. 



KESUME OF EEMEDIES. 
1. UTERINE SEDATIVES AND TONICS. 

Arsenic has been recommended in threatened abortion from 
irritable uterus, by Mr. Henry Hunt, of Dartmouth, 
England. 

Cannabis Indica has been found useful in impending abortion 
from congestion or irritability of the uterus. From 
five to twenty drops of the tincture may be given every 
two or four hours. Drs. Clendening-, Keynolds, 
Lever and Churchill praise its effects. 

Ergota is constantly employed in accidental abortion. (See 
above.) 

Opium is one of the most important agents of this class. (See 
above.) 

Plumbi Acetas is a valuable adjunct to opium in uterine hemor- 
rhage with threatened abortion. 

Potassii Chloras. Inflammatory affections of the placenta are 
a frequent cause of abortions. There is often an in- 
herited predisposition to such affections, and they are 
especially frequent in the strumous and arthritic 
diatheses. Where there are occasional " shows," dis- 
charge of foetid wind, irregular nausea, general exhaus- 
tion, etc., such a condition may be diagnosed. In 
these cases Dr. James N. McDougall (Edinburgh 
Med. Journal, Nov., 1880,) has witnessed the most 
beneficial effects from chlorate of potash and tincture 
of the chloride of iron in full doses in combination. 
21 



322 DISORDERS OF PREGNANCY. 

Frequently these agents, witlr proper hygienic precau- 
tions, will enable the woman to carry the foetus to 
full term. 

Quinine is thought by many to act as a uterine stimulant, and to 
be advantageous in this accident. 

Sabina is useful against the hemorrhage which indicates ap- 
proaching abortion in women of bad fibre, In these 
cases, the dried powder of the leaves may be given, in 
doses of gr. xv.-xx. thrice daily. In habitual abor- 
tion depending upon diminished vitality of the uterine 
system, savin has also been advised : 

281. R. Sabinse, .^ij.-iv. 

Aqua? ferventis, f . ,§ v j . M. 

A tablespoonful thrice daily, taken during the intervals of the 

menstrual period. This remedy must, however, be employed 

with caution. 

Tannicum Acidum, in combination with opium and ipecacuanha, 
has been strongly advised in threatened abortion. 

Terebinthhice Oleum has been favorably reported upon by Dr. For- 
DYCE Barker in the treatment of abortion ; given 
as an enema, he found it to act as an effective oxytocic, 
as well as haemostatic. 

Viburnum Prunifolium is an extremely valuable preventive of 
abortion, often succeeding where other means fail. 
The bark of the root is the portion used, from which 
an extract is prepared. It has been especially noticed 
by Dr. E. W. Jexks. (Gynecological Transactions, 
1876.) 

Emetics. Dr. J. G. Stokes, of Illinois, (Half- Yearly Com- 
pendium, vol. VIII.,) advocates the use of emetics in 
all cases of abortion, especially in those continued cases 
of threatened abortion which are so annoying to both 
physician and patient. 

2. ECBOLTC OR ABORTIFACIENT AGENTS, OR UTERINE EXONE- 

RANTS. 

Aloes. Most of the patent pills sold for the real if not avowed 
object of inducing abortion are composed of aloes com- 
bined with drastic cathartics, the effect of the violent 



ABORTION AND PREMATURE LABOR. 323 

peristalsis induced being to excite by sympathy uterine 
contractions. It is needless to add that this plan is 
both unscientific and dangerous. 

Cantharides sometimes produces abortion through the renal and 
vesical excitement which it causes. As a medical 
means to this end, it is too dangerous. 

Ergota. Probably the most efficient of known ecbolics continues 
to be the various species of ergot, as derived from rye, 
wheat, rice, or maize. It has, however, been denied 
that it acts as such, except in the uterus at term. The 
eminent Dr. Paul Dubois denied that it could pro- 
voke abortion. The correct opinion seems that advo- 
cated by Fonssagrives (Therapeutique, 1878,) that 
its ecbolic action is null at the commencement of 
pregnancy, but increases in direct proportion as the 
latter progresses. 

Gossypium. The fresh bark of the root of the cotton plant, in 
decoction ( 1 iv. of the root to water Oij., boiled to 
Oj.,) in doses of f. 5 iij- repeated, is a popular aborti- 
facient in the southern states. The fluid extracts on 
sale are generally almost or quite inert. 

Jaborandl and Pilocarpin. Considerable attention has been di- 
rected to these agents as ecbolics, and they have recently 
been carefully studied by Prof. P. Muller, of Berne. 
He justly remarks that it certainly would be a great 
advantage if premature labor could be induced by in- 
ternal remedies. All the dangers from traumatism 
and infection would be absent, and the objections 
which now exist against ergot might be found wanting 
in the new agent. But his experiments were not en- 
couraging. To test the contraction-exciting power of 
pilocarpin, Muller gave it to puerperal women, 
whose uteri are particularly susceptible to such ex- 
citants. Multiparas with flaccid abdominal parietes 
and large, readily palpable uteri were chosen, and 
both ergotin and pilocarpin given them. The results 
showed that pilocarpin does not act as powerfully as 
ergot, for if the observations are continued through 
several days, after two days the pilocarpin loses its 
effect. 

Quinias Sulphas. From a mass of evidence laid before the 
American profession, of recent years, there would 



321 DISORDERS OF PREGNANCY. 

seem to be no doubt but that, under some circum- 
stances not yet ascertained, quinine provokes abortion. 
This would appear to be more especially the case 
when administered in large doses in the absence of 
malarial poisoning in the system. 

Huta. The rue is one of the oldest known abortives. Its spe- 
cific action as such, and independent of any intestinal 
irritation, has been abundantly, established by the 
recent researches of Dr. E. Hamelix. [Did. des 
Sciences Med., 1877.) Although uncertain in its action, 
he thinks the uterine contractions to which it gives rise 
are more physiological in character than those follow- 
ing the use of ergot. In administering it, he prefers 
an infusion of the fresh leaves and roots to any other 
form ( 3 ij.-iv. to Water Oj.,) to be taken in two or 
three doses at intervals. 

Sabina. The reputation of this plant as an ecbolic is probably 
not justified. Dr. E. Hamelix, who has studied its 
properties carefully, doubts whether it excites directly 
any uterine action; if such follows, it is the result of 
transmitted irritation. 

Sodii Boras. The use of boras as an ecbolic is of doubtful 
efficacy. 

Tcmacetum, often used for criminal purposes as an abortifacient, 
is, in the opinion of Stilee, incapable of producing 
any such result. 

Hot Water. Dr. J. F. Horne recommends the use of hot- 
water injections into the uterus to cause contraction of 
that organ after abortion. lie uses two pints of water 
as hot as can be borne by the hand, employing an 
ordinary Higginson's syringe with vaginal tube. It is 
found to be much more efficacious than ergot in caus- 
ing expulsion of the placenta and cessation of the hem- 
orrhage. Three successful cases are related. (Obstet. 
Journal, March, 1880.) 



VOMITING ASD NAUSEA OF PREGNANCY. 325 

VOMITING AND NAUSEA OF PREGNANCY. 

DR. EUGENIO BAKBIGLIA OF NAPLES.* 

Ill his very complete study of this subject the above-named 
writer classifies one means of opposing the vomiting of preg- 
nancy under the following headings : 

1. Medical. In the first rank stand alkalies, especially the 
bicarbonate of soda. When gaseous eruptions are present this 
should be combined with charcoal, the latter persisted in in fre- 
quent doses until the foeces are blackened. Aperient salts, in 
small doses, to act on the lower bowels, are frequently of use, 
but all active purgation must be avoided. The bitters stand next 
to the alkalies. Gentian, Colombo, quassia and an gostura or ab- 
sinthe may be used alone or combined. Cinchona combined with 
iron may be demanded in feeble cases. Occasionally the vomit- 
ing has been found to depend upon the presence of intestinal 
worms, in which cases santonine will give prompt relief. Stim- 
ulants, either alcoholic or as strong coffee and tea, benefit some 
cases. The numerous narcotics employed by many physicians 
are rarely of decided efficacy. More can be said in favor of cold 
applied either locally on the stomach by ice-bags, by swallowing 
ice, or by the ether spray to the spine. Dr. 13. mentions espe- 
cially the early use of arsenic. He adds that whatever remedy 
is tried, unless it acts promptly with benefit, it should not be 
persisted in. 

2. Operative Treatment. In plethoric cases, where the menses 
are abundant, a general bleeding may alleviate the symptoms. 
Local bleedings from the os may be substituted in other cases. 
Vaginal injections of alum or acetate of lead may follow these 
incisions. Slight cauterizations of the os with tincture iodine 
or nitrate of silver may take the place of the incisions. Narcotic 
ointments, as of belladonna, aconite, camphor, opium, chloro- 

*Vomito nella Gravidanza, Monograph, p. 48, Naples, 1880. 



326 DISORDERS OF PREGNANCY. 

form, etc., may be applied to the os. If there is displacement 
of the uterus, this should be restored. Other procedures are 
large cups to the epigastrium, compresses wet with laudauum, 
narcotic plasters or ointments, hypodermic injections of morphia, 
etc. 

3. Diet. The patient should be directed to prefer a meat diet, 
small in quantity, and to take food more frequently than usual. 
Longings, however, for unusual articles, should be satisfied. In 
severe cases it may become necessary to support the patient by 
nutritive injections. One of the best is to chop fine a sweet- 
bread, beat it up with glycerine, and add an equal amount of 
lean, raw beef, free from fat and fibre, and thoroughly triturated. 
A syringe, with a large nozzle, is required. 

4. Hygiene. This must be governed by the circumstances of the 
case. Some patients suffer less in motion, others when at rest, 
some during excitement, others when quiet. In all such respects 
their preferences should be consulted. 

When, as will occasionally be the case, all the above means 
fail and serious danger is threatened from debility, there should 
be no hesitation to proceed to artificial abortion. 

DR. J. MARION SIMS. 

This eminent gynecologist observes that, with our present 
knowledge of the treatment of this affection, we should hear no 
more of deaths from pregnancy-vomiting, nor even of mis- 
carriages induced to save the lives of mothers. To the writings 
of Graily Hewitt, Jones and Copeman, we are indebted 
for direct and practical methods of treatment, which seem to 
promise success in the management of these troublesome cases. 
Yet these methods are not without a certain amount of risk, and 
must be cautiously tried. In Graily Hewitt's plan we must 
be careful not to make undue pressure on the cervix uteri with 
the pessary. In Dr. Jones' plan we must place the patient in 
the left lateral semi-prone position, apply a Sims' speculum, ex- 
pose the cervix without touching it with the speculum^ and then 



VOMITING AND NAUSEA OF PKEGNANCY. 327 

pencil the caustic solution on the granular surface, and on that 
alone. In Copeman's plan we must gently insinuate the end 
of the index-finger in the os tincse, and pass it into the cervical 
canal not more than three-fourths of an inch deep. This is to 
be done with the patient on her back. If the uterus should be 
flexed anteriorly, (as it usually is in such cases,) the operator 
must not throw the fundus up and push it back toward the 
promontory of the sacrum with the bi-manual method ; for this 
bi-manual pressure in the early months of pregnancy may pro- 
voke abortion. Of course we should not resort to this heroic 
method of treatment unless the case is urgent and rebellious. 



In summing up his experience in this- complaint, this writer 
(Med. Record, March, 1881,) states that its treatment resolves 
itself into the correction of all disturbances, functional or or- 
ganic, as far as possible, which are known to excite dyspeptic 
symptoms, before a simple irritation becomes a confirmed gas- 
tritis, and the stomach refuses to receive remedies most appro- 
priate to relieve the original trouble. Among these, oftener than 
any others, the emotional element and a constipated habit, with 
its attendant flatulence and discomforts, accompany the pregnant 
state, and should receive early and prompt attention. For the 
relief of the former, no remedies at this time equal in efficiency 
the bromides of sodium and potassium exhibited in full doses. 
And here it may not be amiss to state, that in order to secure 
their full effect these medicines must be administered at the 
proper time, generally late in the day or at bedtime, and when 
the stomach is empty. 

The constipation can be overcome by any simple laxative, as 
the comp. liquorice powder, or any other harmless medicine or 
formula ; or, if obstinate, copious and repeated enemata of tepid 
water will unload the rectum of the hardened faeces or scybala 
which so frequently occur in women. 

Finally, when all other causes are excluded, the constipation 



328 DISORDERS OF PREGNANCY. 

relieved, and the emotional element controlled, and we come to 
consider the purely sympathetic disorder following conception ; 
in short, when we have to deal with the uncommon vomiting, 
due simply and solely, so far as we can see, to the impregnation 
of a healthy uterus in a healthy woman, many of the remedies 
which have been called specifics do sometimes relieve, but often er 
fail. But the one remedy which, in his hands, has before all 
others proved the most efficient for alleviating the distress, if not 
for curing the complaint, is Fowler' 's solution of arsenic, admin- 
istered in drop doses upon an empty stomach. When thus given", 
and with a restricted diet, it has seemed to come nearer to a spe- 
cific for this neurosis than any other. Indeed, the effect is at 
times almost magical, and when continued for a considerable 
period, and given in larger doses when the stomach contains 
food, affords, in my opinion, a nerve tonic highly essential to 
women in the pregnant state, and which no other remedy can 
equal. 

Frequently, however, after its continuance for a considerable 
time, benefit comes from suspending its use and substituting the 
nitro- muriatic acid with tinct. mix vomica, particularly if there 
be any inactivity of the liver or kidneys, or anorexia exists. 



In slight vomitings, some aromatic infusion or tea will gener- 
ally relieve. When they occur after a daily meal, it is useful to 
change the order of the repast. Thus if, as is usual, the vomit- 
ing is very copious after the evening meal, the woman should 
make merely a light repast, and eat more at breakfast. Cold 
food is least likely to be ejected. Ices, aerated waters, or small 
pieces of ice may be taken with the best results. The subacetate 
of bismuth, in doses of a grain or half a grain before each meal, 
is very beneficial ; or after the meal, two or three teaspoonfuls 
of Kirsch. In obstinate cases, a pill, or two or three centigrammes 
of aqueous extract of opium, may be given an hour before the 
meal, and to prevent constipation, a slight purgative occasionally. 



VOMITING AND NAUSEA OF PREGNANCY. 329 

Where the vomiting is accompanied with pain and tension at the 
epigastrium, lotions of laudanum are useful ; or a small blister, 
subsequently powdered with one or two centigrammes of the mu- 
riate or acetate of morphia. Dezon has succeeded by the appli- 
cation of cold water to the epigastrium. Alcohol to a slight in- 
toxication has proved successful; hence champagne frequently 
at once gives relief. Bretonneau has calmed the irritability 
in grave cases by frictions on the stomach with a concentrated 
solution of belladonna. Tarnier applied this in a very bad 
case in the form of the extract to the inferior segment of the 
uterine neck and the vaginal walls with the best results. 

Stackler has succeeded with the black oxide of mercury, 5 
centigrammes daily, without salivation. Eulenberg applied tinc- 
ture of iodine to the os. Ricord and Bacarisse also gave 50 
centigrammes of iodide of potassium daily, and with equal success. 
The salts of cerium, particularly the oxalate, are extremely useful 
in doses of 5 centigrammes, 3 or 4 times a day. 

Obstinate constipation generally is present with the vomiting. 
Hence he gives scammony, 50 centigrammes, with 1 grain of jalap 
at bed-time. If the first is vomited, repeat it immediately, and 
even a third dose. Generally the second or third will be re- 
tained and act purgatively. When an examination reveals a 
retroversion of the uterus, generally its replacement will at once 
put an end to the vomitings. 

In cases likely to prove fatal, especially when the pregnancy 
has advanced to a point that assumes the vitality of the child, 
premature labor may be deemed necessary. 

WM. LEISHMAN, M. D., LONDON. 

Breakfasting in bed and not rising for awhile often speedily 
relieves the trouble. In cases where the bowels are sluggish, 
the granular effervescing citrate of magnesia is useful, or the 
" potion de Riviere " given so that the effervescence occurs 
within the stomach : 



330 DISORDERS OF PREGNANCY. 

282. R . Acid, citric. gr. xxxvj. 

Syr. simp., f.gj. 

Aquse, i.% ij. M 

283. R. Potassii bicarb., gr. xxxvj. 

Aquae, f-^iij- M. 

A tablespoonful of each to be taken successively. When there is exhaus- 
tion, stimulants are required. Pepsin is valuable. Often simple milk, and 
lime-water, and barley-water, (especially the latter,) are retained in very 
grave cases. Nutritive enemata may be employed to sustain the failing 
powers or inunctions of cod or other oils. 



DR. ALBERT EULENBERG, BERLIN. 

284. R . Tincture iodinii, tt\, xv. 

Alcoholis, f-j>iij« M. 

Give three drops several times a day, in a tablespoonful of an aromatic 
infusion. 

285. R . Tincturae iodinii, gtt.x. 

Aqua? destillatge, f. ^ iij. 

Syrupi aurantii corticis, f.^ j. M. 

A teaspoonful, or even a tablespoonful. 

Other approved prescriptions are : 

286. R. Bismuthi subnitratis, ^ iij. 

Acidi carbolici, gr. iv. 

Mucilaginis acacise, ?-,l.i- 

Aquas menthae piperita?, f.^ii], M. 
A tablespoonful three or four times a day. 

287. R. Atropine suiphatis, gr. ij. 

Aqua? destillatae, £^j« M. 

Two drops in water, before meals. 

288. R. Cerii oxalatis, gr. x. 

Bismuthi subnitratis, gr. xxx. M. 

Make ten powders. One five or six times a day. 

Sometimes a rectal injection of chloral hydrate, gr. xxx., morn- 
ing and evening, will effectually control this symptom. Bromide 
of jwtassium, 3 j., thrice daily; chloroform, gtt. ij., in mucilage, 
and medicated pessaries, may also be tried. Dr. E. Copeman, 



VOMITING AND NAUSEA OF PREGNANCY. 331 

of Norwich, Eng., claims invariable success to follow dilatation 
of the os uteri with the finger, once often being sufficient to re- 
lieve the nausea completely. (British Medical Journal, May 25th, 
1875.) A somewhat similar plan is that suggested by Dr. M. 
O. Jones, of Chicago, to wit, painting the os and cervix with 
tincture of iodine, or cauterizing them with solid nitrate of 
silver. This plan has met with great success in obstinate cases, 
and has been endorsed by Dr. J. Marion Sims. (See p. 326.) 

W. STUMP FORWOOD, M. D., OF DARLINGTON, MD. 

Thn practitioner recommends the following as almost a spe- 
cific in the vomiting of pregnancy. {Half-Yearly Compendium, 
vol. III., p. 96) : 

289. R. Columbse, g ss. 

Senme, gj. 

Zingiberis, % ss. 

Aquae bull., Oj. M. 

A wineglassful three times a day. 

HENRY F. CAMPBELL, M. D., OF AUGUSTA, GA., 

Has called attention to the importance of rectal alimentation in 
the nausea and vomiting of pregnancy, not merely as a last 
resort, but as an expedient for supplementing inadequate nutri- 
tion by the stomach in moderately severe cases. (Trans. Am. 
Gyn. Soc.y 1878.) He uses about eight ounces of beef tea, or 
other nutrient liquid, twice daily, injecting it very slowly and 
gently, so as to avoid exciting the low*r bowel to expulsive 
efforts. To supply fluids, during the intervals of the morning 
and evening injections, a full goblet of water, not quite cold, was 
twice given, some hours apart. The results in the instances re- 
ported were highly satisfactory, the nutrition being maintained, 
the nausea abated, and the sympathetic irritation of the stomach 
relieved. 



oo2 DISORDERS OF PREGXAXCY. 

RESUME OF REMEDIES. 

INTERNAL REMEDIES. 

Acidum Hydrocyanicum Dilutum, gtt. v., is a valuable sedative. 

Aconitum. A few drops of the tincture of aconite will relieve 
some cases. 

Armoracia. Dr. Tilt recommends a small portion of horse 
radish scraped fine, and moistened with vinegar. 

Arsenicum. Single-drop doses of Fowler's solution will some- 
times afford astonishing relief. 

Atropia has been used with advantage. (F. 287.) Wm. Boys, 
M. D., Waverly, Iowa, in the Med. Brief, Oct., 1879, 
gives the following : 

290. R . Atropiae sulph., gr. j. 

Morpb. sulph., gr. iv. 

Ac. sulph. arorn., f. ^ iij. 

Aquae, f. 3 v. M. 

Dose, gtt. x.-xx., three times a day. 

Belladonna, in ten-minim doses of the tincture, is recommended 
by Tilt and others. 

Bismuthi Phosphas. M. Tedexap, of France, considers this 
superior to the subnitrate. It acts in smaller doses, 
being more soluble, and is applicable to the same con- 
dition for which the subnitrate is employed. The dose 
is one or two grains for an adult. 

Bismuthi Subnttras will be found at times an efficient sedative. 
(F. 286.) 

Calumba, according to Phillips and Bartholow, will fre- 
quently allay the nausea and vomiting. 

Carbolicum Acidum, in drop doses of the crystallized acid, in 
mucilage, thrice daily, has been recommended by 
English writers. 

Cerii Oxalas has attained great favor. Dr. F. E. Image (Prac- 
titioner, June, 1878,) prefers this formula: 

291. R . Cerii oxalatis, 

Pulv. trag. coinp , aa gr. x. 

Tinct. aurant., f. £ss. 

Aquam, ad f.^j. M. 

For one dose as required. It is often given in too small a dose ; 
gr. x. is required. 



VOMITING AXD NAUSEA OF PREGNANCY. 333 

The nitrate of cerium has also been used. 

Chloral Hydras, in simple nervous erethisms of the stomach, 
often acts promptly; gr. xxx., in mucilage, for a rectal 
injection, is the best form of administration. 

Chloroformum may be given in doses of a few drops in a spoon- 
ful of milk. Sir C. Looock recommended repeated 
chlorcformization almost to insensibility. 

Creosotum should, according to Dr. Ringer, be given in very 
small doses; for instance, added to water, so that the 
latter tastes of it, and then a dessertspoonful of the 
fluid taken from time to time. 

Capri Sulphas, gr. iv. to aquas f.fj. Six drops at a dose will 
sometimes relieve. (Bartholow.) 

Ether. A few drops at a time in water, or inhaled, will at times 
relieve the nausea. The spine has also been sprayed 
with the ether spray with most excellent results, by 
Dr. Dubelski, of Warsaw. 

Hydrargyrum Chloridum Mite. Dr. Tilt occasionally adminis- 
ters gr. x.-xv. of calomel for its sedative action ; or 
combines it in smaller quantities with opium. 

Hyoseyamus. Dr. Pitois, Professor at the Medical School at 
Rennes, reports two striking cases of relief by hyoscy- 
amia. After trying, unsuccessfully, all the usual 
means, he administered a teaspoonful every hour of a 
mixture containing 5 milligrammes of hyoscyamia 
in 125 grammes of fluid. The next day the vomiting 
ceased. ' 

Ingluvin. This substance, used to facilitate digestion, has been 
favorably reported upon. 

Iodinium, iu drop doses of the tincture every hour or two, will, 
according to Bartholow, sometinles greatly relieve 
this symptom. 

Ipecacuanha. Dr. C. Fuller (Lancet, Dec. 4th, 1869,) intro- 
duced the treatment of vomiting of pregnancy by sin- 
gle drop doses of wine of ipecac, in a teaspoonful of 
water every hour. Others have also reported favor- 
able results from this plan. 
Lactopeptin. This peptic compound has in a number of instances 

relieved the nausea and vomiting. 
Magnesia in small quantities occasionally affords relief. 



334 DISORDERS OF PREGXAXCY. 

Nux Vomica, in tincture, gtt. v.-x., as required, is relied upon 
by Playfair and others. Bartholow says it is 
best adapted to cases with much nausea and little 
vomiting, in doses of half a drop to a drop. 

Opium and Morphia are, according to Tilt, the first remedies 
to be tried. He recommends suppositories containing 
gr. ij.-iij. of extract of opium, or gr. j. morphias ace- 
tatis; or the drug may be given by the mouth. 
Inquiry, however, must be made as to the idiosyn- 
crasy, as it is well known that any form of opium pro- 
duces vomiting in some persons. Dr. Atthill com- 
bines morphia with atropia for a hypodermic injection : 

292. R . Morphia? acetatis, gr. viij. 

Atropise liquoris (B. Ph.), TtLxlviij. 

Glycerinae, Tr^v. 

Aquam, adf. 3 iv. M. 

Dose, five to ten drops for a hypodermic injection. 

Pepsina, either as wine or in other forms, will often succeed. 

Potassii Bromidum. Dr. S. C. Busey, Washington, D. C, 
(Amer. Jour. Med. Sci., January, 1878,) has obtained 
decided and immediate relief from the bromide of po- 
tassium. He gives 30 grains to a drachm, dissolved 
in beef-tea, to which brandy and laudanum may be 
added, according to the condition of the patient. He 
gives it in enemata every four hours. Dr. Freidrich, 
in Deutsche** Archiv. fur Klin. Med., Nov., 1879, states 
that he considers the action of bromide of potassium, 
given in doses of from one to two grammes a day, so val- 
uable that he would be almost disposed to say that we 
possess in bromide of potassium a specific remedy 
against the obstinate vomiting of pregnancy, if it were 
permissible to speak of specifics in such a case. 

Potassii Iodidum is occasionally of service. 

SaUcin has been occasionally found to be of service. 

Strychnia. Dr. Tilt strongly recommends : 

293. R. Strychnia, gr.J. 

Tine, zingiberis, f. 3 vj. 

Aquae, £Jfiv. M. 
Dose, a teaspoonful every one or two hours. 



^ VOMITING AND NAUSEA OF PREGNANCY. 335 

Tannicum Acidum, in the form of a pill, gr. i.-ij., morning and 
evening, has been found very successful by Dr. 
Dibove. (Arch, de Tocologie, Sept., 1877.) 

Stimulants. Recourse must be had to these cautiously, on ac- 
count of the relief they sometimes give, leading to the 
habit of tippling. When accessible, the best is prob- 
ably dry champagne, iced, of which tablespoonful doses 
may be given every fifteen minutes. 

Tobacco-smoke has been recommended by Gros. It may be in- 
haled, or may be injected against the os. 

LOCAL MEASURES. 

Caustics. Dr. J. Marion Sims believes that the treatment 
should always be directed to the seat of the irritation, 
and claims the best results from the use of caustic to 
the os; two or three applications generally suffice. 
This method he employs even when there is no sign of 
erosion of the mucous lining of the os, and the parts 
appear perfectly healthy. Dr. F. D. Lente [Med. 
Record, 1879), agrees with Dr. Sims, and freely touches 
the os and cervix with the nitrate of silver. He quotes 
Dr. M. O. Jones, Chicago, as using this method with 
the best possible result, and where, in the majority of 
cases, the os presented no signs of disease. Dr. Play- 
fair considers the measure hazardous. 

Cold, applied to the epigastrium, or by swallowing pieces of ice, 
is often beneficial. 

Electricity. Dr. T. Gaillard Thomas, of New York, employs 
electricity. He fixes one broad flat electrode, made by 
stitching a flat sponge to sheet rubber, by means of 
adhesive plaster on the epigastrium, and a similar one 
under the spine, the patient lying supine. Then a gentle 
current is passed, and continued steadily for ten, twelve, 
or even twenty-four hours. He has seen no evil 
result, and esteems this remedy higher than any other. 
Dr. da Venezia relates in the Giornale Veneto di 
Science Med. (January, 1879,) a case of chronic nervous 
vomiting in pregnancy which was cured by electricity. 
The patient was a young woman aged twenty-four, in 
the seventh month of her first pregnancy. She had 
been suffering for the last two years from frequent 



336 DISOEDEES OE EEEGXANCY. 

attacks of vomiting after food, which had been so fre- 
quent during the last month, that she had become 
greatly reduced in strength. The usual therapeutic 
agents were then employed ; but, as no relief was 
obtained through them, the author resolved to try 
electricity. A farad ic current of moderate strength 
was used, one of the rheophores being applied to the 
side of the neck along the course of the vagus nerve, 
and the other to the epigastrium. After the first 
sitting the patient was better, and after the fourth the 
vomiting ceased. 

Heat. Tannee mentions hot fomentations to the epigastrium 
and hot poultices, as occasionally useful. 

Injections, either rectal or vaginal, are efficient means. Those 
containing opium are most useful. In the Boston 
Medical and Surgical Journal, 1879, Dr. Geeene, of 
Dorchester, advocates the use of warm vaginal lave- 
ments for many cases of obstinate vomiting of preg- 
nancy. He also reports a case where warm olive oil 
succeeded after the water had failed. 

Leeches to the os have been used by Clay, but their propriety 
has been doubted by Playfaie. Dr. Tilt mentions 
that in some cases the vomiting has been promptly 
checked after the failure of ordinary measures, by the 
application of a few leeches to the pit of the stomach, 
although there were no signs of inflammation there, 
and the patient was not plethoric. 

Suppositories, both rectal and vaginal, containing opium or its 
alkaloids, are among the earliest resources indicated. 
As a medicated pessary, Dr. Tanxee prescribes : 

294. R. Extracti belladonnse, gr. xxv. 

Extracti hyoscyami, gr. lxxx. 

Plumbi iodidi, ^j. 

Theobromse cocofe, %]. 

Oleiolivse, f-.^ij- M. 
For eight pessaries. One to be introduced into the vagina every 
night. 

Oxygen Inhalations. In some obstinate cases Dr Plxaed 
tried, with immediate relief, inhalations of oxygen, led 
thereto by the fact that the vomiting of chlorotic sub- 
jects is often relieved by this means. (Annates de 
Gynecologie, May, 1880.) 



SYMPATHETIC NERVOUS DISORDERS. 337 



SYMPATHETIC NERVOUS DISORDERS. 

These are palpitation of the heart, headache, syncope, cough, 
neuralgia, pruritus, and other cutaneous diseases, hypochondriasis, 
affections of the sight, etc. 



For the palpitation, would give ferruginous preparations, and a 
general tonic regimen. When it does not seem to result from 
debility, antispasmodics are indicated. 

Syncope occurs generally in women of a highly-developed 
nervous temperament, and generally about the time of quicken- 
ing. The treatment should consist in the use of diffusible stimu- 
lants, as ether, ammonia, and valerian, the patient being recum- 
bent with the head low. In the intervals, tonics and iron are 
necessary. 

Neuralgia is generally controlled by tolerably large doses of 
quinine. If caries of the teeth are present, the affected tooth 
should be removed without fear. Nitrous oxide gas may be 
administered without difficulty or risk. 

ELY VAN DE WAEKEE, M. D., OF NEW YORK. 

This writer extols the black cohosh, cimicifuga racemosa, for 
the nervous disorders of pregnancy. (Half- Yearly Compendium, 
vol. XIIL, p. 176.) He says: 

" Women are oftentimes the subjects of distressing symptoms 
as pregnancy advances. Among these are a train of nervous 
symptoms: Kestlessness, sleeplessness, darting pains in the 
back, flanks and thighs, and stiffness and soreness in movement, 
are very common and troublesome. For these conditions I find 
black cohosh, cimicifuga racemosa, a sovereign remedy. I give 
thirty minims, or half a teaspoonful, of the fluid extract at bed- 

22 



338 DISORDERS OF PREGNANCY. 

time, in cases of restlessness ; and in cases of neuralgia of the 
lumbar or abdominal muscles, or in cases of stiffness or soreness 
in movement, the extract may be given in the same amount, at 
intervals of three to five hours during the day." 

THOMAS H. TANNER, M. D., LONDON. 

The headaches of pregnancy are usually due either to debility 
or to sympathy. The first is dull and steady, the skin cool, and 
the pulse feeble. Its successful management demands quinine 
and iron, good diet, exercise, and general hygiene. The sympa- 
thetic headache is generally limited to a small space, or a single 
spot. The pain is acute and penetrating. The treatment is a 
moderate purgative followed by tonics. The extract of aconite, 
gr. ss., every four or six hours, sometimes gives prompt relief in 
such cases. 

In puerperal cases, insomnia is not unfrequently the precursor 
of delirium or mania. It demands, therefore, careful attention, 
and, if persistent, the cautious use of hypnotics. 

Groundless despondency, hypochondriasis, is net very unusual 
during the period of gestation. The bowels should be acted on 
with rhubarb and soda, pepsin taken after the meals, and a tonic, 
such as the following, be prescribed : 

295. R • Spiritus ammonia? aromat., f. % iij. 

Spiritus chloroformi, f . ^ ij . 

Ferri et quiniae citratis gr. xxx. 

Liquoris strychnia?, Tr\,xxx. 

Tinctura? zingiberis, f-.^ij- 

Aquam, ad f.^viij. M. 
A sixth part two or three times a day. 

Sometimes the union of the tonic with an alterative is desira- 
ble, as : . . 

296. R. Ammonii muriatis, gr. lx : 

Extracti cinchona? liquoris, n^xc. 

Vini rhei, f.% vj. 

Aquam menth. piper., ad f.^ viij. M. 
A sixth part twice daily. 



SYMPATHETIC NERVOUS DISORDERS. 339 

The moral management of such cases is also important. Posi- 
tive assurances of the future must be given ; the demeanor must 
be humane and sympathizing; and she must be guarded from 
scenes and tales of suffering. 

Pregnant women toward the eighth month are sometimes sub- 
ject to sudden attacks of intense!} 7 acute pain in the right side. 
The treatment should be to make the patient lie on her left side, 
cover the region of the pain with hot fomentations containing 
belladonna and opium, and administer a full dose of an anodyne 
and carminative mixture. As long as any pain remains, she 
should keep her bed, and lie on the left side. 

The sympathetic nervous cough of pregnancy comes on in vio- 
lent paroxysms, especially at night, without expectoration or steth- 
oscopic signs. In its treatment, he has found antispasmodic 
mixtures like the following to give great relief: 



297. R Spiritus etheris, 




f-3"J. 


Tinct. chloroformi comp., 




*3J. 


Acidi hydrocyanici diluti, 




*lxv. 


Liquoris morphias sulphatis, 




f.3J- 


Tinct. cardamomi comp., 




£5 V J\. 


Aquam, 


ad 


f.^Vilj, 


A sixth part every six or eight hours. 






Or, 






298. R . Tinct. Valerianae ammon., 




TTLXXX. 


Tinct. sumbulis, 




tt\XX. 


Tinct. belladonnae, 




rtix. 


Tinct. camph. comp. 




rr\xxx. 


Aquam camphorse, 


ad 


f.£xij. 


For one dose. 







M, 



M. 



Efforts must be continued to check the cough when violent, as 
its continuance sometimes leads to abortion. 

CUTANEOUS AFFECTIONS. 
TYLER SMITH, M. D., LONDON, 

Regards pruritus as the result of follicular irritation of the 



340 DISORDERS OF PREGNANCY. 

vulva. The secretion from the surface is generally very acid, 
which may be relieved by washing with common yellow soap. 
Dilute hydrocyanic acid, Battley's solution, of each f. 3 ij., and 
carbonate of soda, 3 ij,, water f. 5vj., make an excellent wash, 
using only a tablespoonful at a time. A lotion of borax is good; 
sometimes an acidulated lotion is preferable, or a lotion of tar- 
water. In obstinate cases, paint the vulva with nitrate of silver, 
ten grains to water one ounce, every day or every other day; or 
with tincture of iodine with an equal part of water. Where 
the os uteri is thus troubled, inject the lotion of borax or nitrate 
of silver. Tepid or cold bathing, cooling diet, and aperients, 
are also aids in the cure. Should it assume a periodic form, 
quinine is the remedy. 

PROF. W. S. PLAYFAIR, M. D., LONDON. 

Pruritus is frequently associated with leucorrhcea of an acrid 
nature ; or there may be aphthous patches on the mucous mem- 
brane, ascarides in the rectum, or pediculi in the hairs of the 
mons and labia. Sedative lotions are useful, as Goulard's, or an 
ounce of the solution of muriate of morphia with a drachm and 
a half of hydrocyanic acid in six ounces of water; or chloro- 
form, one part to six of almond oil. A pledget of cotton-wool 
soaked in equal parts of glycerine of borax and sulphurous 
acid, may be placed in the vagina at bed-time, and removed in 
the morning. In obstinate cases, the solid nitrate of silver may 
be brushed lightly over the vulva. Generally the aperient 
mineral waters and bromide of potassium aid in the cure. 



Gives this formula : 



299. R . Deutochloride of mercury, 2 grammes. 

Alcohol, 10 " 

Rose water, 40 " 

Distilled water, 450 " M. 



SYMPATHETIC NERVOUS DISORDERS. 341 

He employs this night and morning thus: Bathe the parts 
with warm water to remove any discharges, then, having carefully 
dried the surface, rapidly sponge the seat of the affection with 
the lotion. In a few minutes, wash again with fresh water. 
The cure is generally rapid. 

Occasionally a dose of pilocarpin has been found promptly to 
relieve the troublesome symptom. 

[For further suggestions regarding the Pruritus of Preg- 
nancy, see part I., chap. III., under Pruritus of the Vulva.] 

One of the most common of cutaneous affections are Ephelides. 
Prof. Neumann recommends for them : 

300. R . Acidi chrysophanici, 1 part. 

Adipis, 40 parts. M. 

Gently anoint the part, previously washed with soap and 
water; then apply a piece of linen, to prevent staining. Repeat 
the application three or four times at two days 7 interval, being 
careful not to touch the eyelids and not to apply too strong an 
ointment on persons of delicate skin. The parts to which it is 
applied become red, then black ; the skin desquamates, and the 
stain disappears. The same remedy may be used for pigmentary 
stains occurring independently of pregnancy. 

Urticaria and herpes gestationis are other forms of skin disease 
associated at times with the pregnant condition. Their treat- 
ment at that period is often more delicate and less successful, 
but in general principles is not different from under ordinary 
conditions. 

affections of the eye. 

The diseases of the eye occurring in connection with preg- 
nancy, have been studied hy Mr. Henry Power. (Lancet, 
May, 1880.) 

He commences by reviewing the physiological changes induced 
by pregnancy, and concludes that the quantity of blood, though 



342 DISORDERS OF PREGNANCY. 

increased absolutely, is not relatively, and that in pregnancy a 
condition of general anaemia is far more commonly met with 
than one of hyperemia. • 

From an examination of the various cases which have fallen 
under his notice, he would classify the diseases of the eye in con- 
nection with pregnancy under three heads, namely : 1. Affec- 
tions depending on general anaemia and exhaustion ; 2. Those 
consequent on some special lesion of the nervous system ; 3. 
Those depending upon, or rather associated with, albuminuria. 

Among diseases attributable to exhaustion, the most common 
are ulcers of the cornea, which may be either spontaneous or 
arise from some slight injury. They are often central, are slow 
in their progress, and are not usually dangerous. The treatment 
may be summed up in two words, rest and tonics. The former 
indication may be fulfilled by a two or four-grain solution of 
atropine or eserine, and the application of a pad of cotton- wool 
and a bandage ; the latter by quinine. During lactation, a more 
dangerous form of ulcer is often met with, causing destruction 
of the cornea, with eventually atrophy of the globe. Paracen- 
tesis corneae is .often required in such cases. 

Another sign of exhaustion in pregnancy is impairment of the 
power of accommodation, due to enfeebled action of the ciliary 
muscle. Glasses, in suitable cases, will necessarily be required, 
but much good also may be effected by tonics, especially strych- 
nia in small doses. As regards special lesions, the author has 
witnessed what he considers an increased tendency to lachrymal 
abscess, and to the development of cataract. Lesions of the 
nervous system, or lesions implicating the nervous apparatus of 
the eye generally, he divides into two groups, the intra and the 
extra-ocular. The former affect the retina, the latter the optic 
nerves, chiasma, optic tract, and central ganglia. The retinal 
affections are almost limited to cases of albuminuria, though, 
also, cases of hemorrhagic glaucoma, and miliary hemorrhages 
unconnected with albuminuria in pregnancy have been noted by 
Galezowski. Two cases are recorded by the author^ in which 



SYMPATHETIC NERVOUS DISORDERS. 343 

retinal hemorrhages during pregnancy passed off harmlessly, and 
one in which they were of fatal significance. 

As regards the treatment of such cases, it is the same as that 
of retinal disease generally, no special treatment being de- 
manded for the eyes. Some writers have recommended the 
induction of premature labor in these cases, but the author con- 
siders more data are required before a positive opinion can be 
pronounced, more especially as to the period when labor could 
best be induced. As regards intracranial diseases in pregnancy, 
the author suggests they Could almost be classed under the head 
of " anomalous affections." He gives the histories of cases of 
partial or complete loss of vision from post-partum hemorrhage, 
and explains such either by abolition of the circulation in some 
portion of the cerebrum, or by some lesion of the delicate tissue 
of the central nervous system from sudden diminution of 
pressure. Many such cases, eventually resolve themselves into 
atrophy of the optic disc. 



341 DISORDERS OF PREGNANCY. 



DIGESTIVE DERANGEMENTS OE PREGNANCY. 

GINGIVITIS, PUERPERAL SALIVATION. 

Dr. A. Pinard, of the CUnlque cV 'Accouchement, of Paris. 
(IJAbeille Med., Jan., 1878,) remarks that in many cases of preg- 
nancy the gums are the seat of more or less morbid phenomena. 
They are redder and more congested than normally ; they are 
swollen; the edge of the free border, especially the inter-dental 
membrane, covers a part of each tooth. The slightest pressure 
exerted on this edge, causes a slight hemorrhage. At a more 
advanced degree, the teeth lose their solidity. The mastication, 
at first injured, becomes more painful and more difficult as the 
lesions are more pronounced. 

For the relief of this condition, he has used : 

301. R . Chloral hydratis, 

Tinct. cochleariae off., aa partes equales. 

Apply daily, or every other day, to the diseased edge of the gums, with a 
mop. 

This dressing is slightly painful, and the cauterization very 
light. The eschar disappears generally twenty-four or thirty- 
six hours after the application. In thirty women attacked with 
gingivitis, who were subjected to this treatment, twenty-five 
were cured in less than fifteen days. In two of them the cure 
was slower, complications having supervened which necessitated 
the use of mercurial ointment. In five others the treatment 
could not be continued. 

Dr. Thomas H. Tanner remarks that some writers say the 
salivation should not be checked ; but he distrusts this view. 
He has found small blisters behind the ears or to the neck more 
efficient than any other remedy. Local remedies are seldom of 
use ; one of the best is : 

302. R. Sodii boraeis glycerini, £,?ij- 

Aquse rosae, f-3 v J- M 

For a gargle. To be used twice daily. 



DIGESTIVE DERANGEMENTS OF PREGNANCY. 345 

Belladonna is the only internal remedy he lias seen diminish 
the discharge, but this often fails. Chlorate of potassa may be 
tried. 

DIARRHGEA 

Occasionally is present, and Playf air regards it as due to errors 
of diet. It should not be neglected, as it may bring on labor 
prematurely. The chalk mixture, with aromatic confections 
and small doses of clorodyne and laudanum, will generally 
check it. 

Leishman counsels the removal of any faecal accumulations 
by castor oil and then the use of astringents. 

CONSTIPATION. 

Leishman regards this as due to the pressure of the womb 
on the bowel, reducing its calibre and paralyzing its muscular 
fibres. In other cases, a want of bile occasions it. If clay- 
colored stools show this, a few grains of blue pill will do good. 

Playfair suggests appropriate diet, as fresh fruits, brown 
bread, oatmeal, etc. The aperient mineral waters answer well, 
and an occasional dose of confection of sulphur; or a pill of 
three grains of extract of colocynth, quarter of a grain of ex- 
tract of nux vomica, and a grain of extract of hyoscyamus at bed- 
time ; or a teaspoonful of compound liquorice powder, at bed-time. 
This condition is effectually combated by giving, twice a day, a 
pill of two grains of inspissated ox-gall with a fourth of a grain 
of extract of belladonna. Enemata of soap and water are good. 
Scybalse must be broken up and removed by mechanical means. 

Dr. W. Craig, Edinburg, [Edinburg Med. Jour., June, 1875,) 
has found the following an excellent pill for the constipation so 
common in females of a sedentary habit : 

303. R. Aloin, gr. ss. 

Ferri sulph. exsic, gr. iss. 

Extract, nucis vomicae, 

Extract, belladonna?, aa gr. ss. M. 

Ft. pil. One or two pills daily. 



346 DISORDERS OF PREGNANCY. 

Another writer gives : 

304. R. Ext. colocyntb. comp., gr. xij. 

Pulv. rhei, gr. vj. 

Ext. belladonnas, gr. iss. 

Ext. hyoscyami, gr. iij. M. 

Divide into six pills. One at bed-time. Gr. ^ of strychnia may be 
added to each pill. 

ICTERUS GRAVIDARUM. 

Dr. J. Wickham Legg,* in a recent work, s'ates that this 
form of jaundice usually comes on toward the end of pregnancy, 
and then lasts till after delivery. When simple in form, the treat- 
ment should not be active. The bowels must be regulated by 
mild laxatives, and small doses of the alkaline soda salts given 
by the mouth as well. The older writers specially note that 
emetics must not be employed, on account of the danger of caus- 
ing abortion. 

There is one form of jaundice in which abortion is very com- 
mon. This is a species of icterus gravis, and at times is of the 
nature of an epidemic. Nearly all attacked with it miscarry, 
and a certain proportion of them die with it. The phenomena 
of the disease do not appreciably differ from those of ordinary 
acute yellow atrophy. The treatment should begin with a smart 
mercurial purge, followed by sulphate of magnesia or soda. 
This may be followed by quinine in large doses, with an admix- 
ture of the mineral acids. Locally, a warm linseed poultice 
over the epigastric and riglit hypochondriac region. The prog- 
nosis is grave. 

HEMORRHOIDS. 

Leishman says the treatment must be purely palliative. 
Sponging with water ; fomenting with sponges wrung out of 
hot water, and applied as hot as they can be borne ; applica- 
tions of ung. gallag cum opio ; and cold injections for hemor- 
rhage. 

* On the Bile, Jaundice and Bilious Diseases, 1880. 



DIGESTIVE DERANGEMENTS OF PREGNANCY. 347 

Cazeaux gives every night a cold enema ; when this is 
evacuated, a second of about one-fourth the quantity; this to be 
retained. 

Playfair likes the sulphur electuary. When tender and 
swollen, lie covers the tumors with an ointment of four grains 
of muriate of morphia to an ounce of simple ointment. 

B,. P. Harris, M. D., adds to the ung. gallse cum opio % j., 
ext. of stramonium 3j. The tumors should always be returned 
carefully within the spincter, and punctured, if necessary, to 
lessen the congestion, prior to the attempt at reduction. 

Tarnier relieves the constipation, then uses cataplasms and 
lotions, emollient and narcotic. When internal, introduce sup- 
positories within the rectum. Opium and belladonna are most 
useful. 

During pregnancy and the puerperal period, hemorrhoids 
often occur. For them Dr. Barker recommends the following 
formula : 

305. R. Pulv. aloes Soc, 

Sapo cast, aa J}j. 

Ext. hyoscvami, £ss. 

Pulv. ipecac, gr. v. M. 

Divide in pills No. xx. Sig. — One morning and evening. 

When the hemorrhoids are associated with an irritable rectum, 
and with frequent small, teasing, thin evacuations, he substitutes 
for the hyoscyamus a small quantity of opium, giving also a less 
quantity of aloes, as in the following formula: 

306. R. Ferri sulph., J}j. 

Pulv. aloes, gr. x. 

Ext. opii aq., gr. x. 

Sapo cast., gr. x. M. 

Ft. pil. No. xx. Sig. — One morning and evening. 

Locally he applies the following ointment to the tumors and 
well up in the rectum twice daily : 

307. R. Ung. gall se com., 5fj. 

Ext. opii aq., ^j. 

Sol. ferri subsulphatis, f-5J. M. ft. ung. 



348 DIS03DEBS OP PREGSTAUCY. 

ALBUMINURIA OF PREGNANCY. 

PEOF. WM. LEISHMAN, M. D., GLASGOW, 

Says antiphlogistics must only be used with the greatest caution. 
Baths are useful by promoting the function of the skin. Diu- 
retics are of doubtful value. 

Dr. J. S. Parry, the Philadelphia editor, urges the following : 



308. K. Tr. ferri chlo., f-.^iij. 

Liq. ammon. acet, f-^iij- 

Ac. acetic, T^xy. 

01. gaultheriae, gtt. v. 

Syr. aurant. cort., f.^ j. M. 

Dose, one to two drachms three times a day. 



It is of great importance to recognize the presence of albumen 
early. Such symptons as oedema, even of the minor form, should 
always prompt the physician to test the urine for albumen. It 
may, indeed, exist, and apparently in no way affect the general 
health. When this is the case, active medication is needless. It 
will be enough to regulate carefully the diet, and maintain in 
normal action the secretory functions. Cases which are wholly 
due to the pressure of the enlarged uterus and its contents, often 
continue to the close of the pregnancy, and pass through confine- 
ment without any untoward accident. The avoidance of inter- 
ference, therefore, and a watchful supervision of the case, em- 
brace all that the physician is called upon to do. It must be 
borne in mind that the disease is one of debility, and implies 
impoverishment of the blood, so that lowering treatment is 
usually out of place, and tonics and a general diet are rather 
called for. Occasionally some of the mildest diuretics may be 
exhibited, but, as above mentioned, their generous use is of ques- 
tionable propriety. 



ALBUMINURIA OF PREGNANCY. 349 

PROF. W. S. PLAYFAIR, M. D., LONDON. 

Saline diuretics, as acetate or bitartrate of potassa, and watery 
purgatives, as the compound jalap powder, are most useful in 
promoting the urinary secretion and relieving the renal conges- 
tion. Dry-cupping over the loins, frequently repeated, and the 
vapor or Turkish bath, will aid greatly. The diet should be 
mainly of milk and white of egg, and a little white-fish. The 
tincture of perchloride of iron, with the tincture of digitalis, 
acts well. The induction of labor must depend upon the gravity 
of the symptoms. 



M. 



Believes in small bleedings where there is distinct lumbar pain 
and general febrile excitement, or cups to the loins, or sinapisms. 
Warm and vapor baths, aided by diuretics, as acetate of potassa, 
*)il of juniper, infusion of broom, will tend to remove the effusion, 
and cause the kidneys to act. Then tonics, iron, and good diet. 
Where the phosphatic diathesis exists, we require the mineral 
acids, opium, and rest. 

PROF. S. TARNIER, PARIS, 

At the Maternite, has for some years treated albuminuria en- 
tirely by milk, and with most excellent results. One litre 
(If .pints) of milk, increased to three and four litres a day, are 
given, and the albuminuria rapidly diminishes or disappears. 
The effect is shown in a week or a fortnight. 

PROF. MONTROSE A. PALLEN, M. D., NEW YORK, 

Regards as the correct treatment the relief of the hyperemia of 
the kidney by sponging the surface with hot water and alcohol, 
and by keeping the pores open with vaseline inunctions; to this 
may be added the hot-air or Turkish bath ; milk is given as the 



350 DISORDERS OF PREGNANCY. 

most digestible food; koumiss was added because of the very 
slight amount of, and easily digested alcohol in it. The patient 
is to be kept in bed, to maintain the skin at a uniform temper- 
ature ; massage stimulates the circulation, and equalizes the blood 
current ; cathartic water is the best aperient. If eclampsia is 
threatened, have recourse to chloroform, and bleeding. 

PROF. EDW. S. DUXSTER, M. D., ANN ARBOR, MICH. 

In treating of the prophylaxis of puerpe?*al convulsions, this 
author suggests in albuminuria, the relief of the congestion of 
the kidneys by causing the skin to act; he gives bitartrate of 
potassa, compound jalap powder, citrate of magnesia, and sul- 
phate of magnesia acidulated with sulphuric acid, and the natural 
mineral waters. He promotes diaphoresis by the vapor and hot- 
air bath, or the Turkish bath, if accessible. Vichy and Seltzer 
waters are well borne. Cupping, wet or dry, over the kidney, 
particularly when there is pain over it, and the urine is scanty,* 
or smoky. A hard, bounding pulse, severe pains in the head, 
flushed and hot skin may be met by venesection, though in many 
instances saline laxatives, freely used, will overcome these symp- 
toms. 

Counteract the impoverished state of the blood resulting from 
the loss of albumen by good nutritious food, fresh air, an appro- 
priate mode of life and tonics. Generally white meats and fish 
are well borne. Milk is excellent as a diet. The tincture of the 
chloride of iron is the best tonic. It should be given largely 
diluted, and not to the extent of blackening the faeces. 

Quiet the nervous and digestive disturbances by complete reg- 
ulation of the habits and mode of life, and an out-door life short 
of fatigue; constant and cheerful occupation for both mind and 
body. Avoid opiates, but give nervous sedatives or soporifics 
that are non-constipating, as chloral, in severe cases. The bro- 
mide of potassium and the monobromide of camphor are useful. 
They ameliorate the condition, and give considerable immunity 
against convulsions at the time of labor. For the loss of appe- 



ALBUMINURIA OF PREGNANCY. 351 

tite and constipation, pepsin, bismuth, and nux vomica, are ser- 
viceable. 

Induce premature labor when all else fails. 

DR. A. S. COE, OF NEW YORK. 

According to this practitioner (Am. Jour. Obstetrics, October, 
1878,) when albumen makes its appearance early in pregnancy, 
there are three important indications to be met : (1) to eliminate 
the poison as far as possible ; (2) to support the patient ; (3) to 
allay the nervous tension, and guard against exciting causes. In 
the first, acetate or some of the other salts of potassa, with dig- 
italis, acts favorably upon the kidneys, and diminishes the quan- 
tity of albumen in the urine. Much of the poison can be elim- 
inated by the action of saline cathartics upon the bowels. The 
second is best met by a liberal diet, tonics, and iron. To meet 
the third, absolute rest and quiet are necessary, with the use of 
opium and bromide of potassium, if an outbreak of convulsions 
or other paroxysms is threatened. When there is much cerebral 
disturbance, the application of ice to the back of the head and 
upper part of the spine answers an excellent purpose. 

Convulsions are usually preceded by a rapid accumulation of 
uric poison in the blood and a scanty secretion of urine, and 
often the patient is attacked with only a slight premonition of 
coming disaster. In the treatment of these cases, he has found 
that sulph. morphia, injected hypodermically, answers the best 
purpose. He never was able to get satisfactory results from 
bleeding or the use of chloroform. 



PROF. J. B. FONSSAGRIVES, M. 

This author considers it doubtful whether any direct means 
are available to combat the superabundance of albumen in the 
serum; but indirectly much can be done by regimen and diet. 
One of the most important points -is to keep the bowels soluble 
by laxatives ; constipation in such cases must be sedulously 



352 DISORDERS OF PREGNANCY. 

avoided by means of alkaline purgative waters, in doses suffi- 
cient to act moderately and no more. 

Whether the diet recommended in Bn'ght's disease should also 
be adopted in the albuminuria of pregnancy, remains an open 
question. Often by attention to the bowels and general regimen, 
no such means need be resorted to. 

PROF. KARL R. BR ATTN, M. D., VIENNA. 

Hydrsemia, at an early stage of pregnancy, is ameliorated by 
nutritious diet, vegetable tonics, and iron, tepid baths, and espe- 
cially vapor baths. To neutralize the carbonate of ammonia in 
the blood, make use of benzoic acid, lemon juice, or tartaric acid. 
To obviate congestion of the head, prevent constipation by vine- 
gar injections, aloes, jalap, etc. When exudation has taken 
place into the Malpighian capsules, and the tubuli of Bellini and 
Ferrein, the cylindrical clots must be removed from them, and 
new ones prevented. If the current of fluid from the bodies 
into the capsules be strong, then the copious use of diluents will 
suffice to wash away the clots. But if the urine be scanty and urae- 
mia threaten, then the force of the current must be increased by 
acids, as above, and Seltzer and Vichy waters. Pills of tannin 
and extract of aloes are useful to restore the normal tone. 

Premature delivery is not to be thought of, unless uraemia has 
appeared, and the life is threatened. But it will be rational to 
resort to this procedure if, from the duration of the disease, its 
severity, the quantity of cylindrical clots, the great hydrsemia, 
the dropsy, and disturbances of the heart, lungs, brain, etc., cause 
fear of the existence of great degeneration of the kidneys. Should 
symptoms indicate the death of the foetus, operative interference 
may at once be employed, as its retention greatly adds to the 
danger to the mother. 

KESUME OF KEMEDIES. 

Benzoicum Aciduni, gr. v., twice daily, in pill form, has given 
satisfactory results in urseraic attacks during preg- 
nancy. 



ALBUMINURIA OF PREGNANCY. 353 

Chloral has been tried with marked success in a few cases by 
Dr. E. JNToeggerath, of New York. (Amer. Jour, 
of Obstetrics, Oct., 1878.) He gave gr.xx.,-xxx. every 
night, with the result that the albumen immediately 
began to diminish, and soon disappeared entirely. 

Digitalis. The diuretic powers of this drug are frequently avail- 
able. It can often be advantageously used as a poul- 
tice, as recommended by Dr. P. C. Russell. (Brit. 
Med. Jour., Dec, 1878.) 

Ferritin. The use of ferruginous preparations combined with 
diuretics is always indicated. 

Hydrargyrum. All preparations of mercury should be given 
with great caution in albuminuria, as such patients are 
intolerant of this drug. 

Jaborandi and Pilocarpin must be used cautiously in these cases, 
as they have ecbolic properties which may lead to 
abortion. 

Oleum Juniperi was preferred by Simpson as a diuretic, but has 

not been approved by others. 
Oleum Tiglii is occasionally called for in severe cases, to act on 

the bowels and kidneys. 

Potassii Acetas and Bitartras usually secure an abundant renal 
secretion. 

Potassii Bromidum is valuable to relieve headache and control 
nervous excitement. 

Milk Diet. A diet of skimmed milk is probably the only remedy 
now known which has a radical influence on albumin- 
uria. 



[On the general treatment of Albuminuria, see the section on Eclampsia, 
and also Napheys' Medical Therapeutics, chap. V.] 

23 



CHAPTER II. 



COMPLICATIONS, DISORDERS, AND SEOUELE 
OF PARTURITION. 

Anaesthetics in Labor — Antiseptics in Labor — Placenta Prcevia— 
Tedious Labor (Rigid Os, Uterine Atony, etc.) — After- Pains — 
Puerperal Hemorrhage — Puerperal Eclampsia — Puerperal 
Mania — Puerperal Septicaemia — Thrombosis and, Embolism — 
Shock — Pelvic Cellulitis and Peritonitis (Puerpercd Phlebitis 
and Metritis) — Phlegmasia Dolens — Milk Fever — Puerperal 
Convalescence — Coccygodynia. 

ANESTHETICS IN LABOR. 

PROF. FORDYCE BARKER, M. D., NEW YORK. 

Anaesthetics are of great value in preventing lacerations of the 
perinseum. In that form of rigidity caused by excessive irrita- 
bility of the muscular fibres, the perinseurn relaxes and dilates 
with remarkable rapidity after the inhalation of chloroform . 
Where danger arises from violent uterine contractions, profound 
anaesthesia will save the perinseum. Even in tedious labors, chlo- 
roform causes relaxation and a restoration of the normal moisture 
and temperature of the parts, and efficient action of the uterus is 
at once resumed. 

PROF. KARL SCHROEDER, BERLIN. 

Chloroform in labor has the same advantage as in surgical 
operations. It facilitates all midwifery operations. In parturition, 
it easily acts in a small quantity, and it is not necessary to pro- 

355 



356 COMPLICATIONS OF PARTURITION. 

duce complete anaesthesia merely to mitigate pain. A few whiffs 
relieve the acute pain, and this cannot injure mother or child. 
Even profound anaesthesia has not been found to influence the 
child, when continued for a short time. 

It does not induce hemorrhage, and reduces the temperature, 
both favorable effects. 

It cannot be questioned that chloroform is advisable in normal 
parturition to suppress the intense sufferings. Chloral has an 
equally beneficial effect. 

PROF. S. W. PLAYFAIR, M. D., LONDON. 

Anaesthesia is a perfectly legitimate means of assuaging the 
sufferings of child-birth. Chloral may be safely given when 
chloroform cannot. It does not relax contractions, while it pro- 
duces a drowsy state, in which the pains are not so acutely felt. 
Hence, in the fii^t stage, during the dilatation of the cervix, it is 
most useful ; especially in those cases where the pains are intol- 
erably acute, with but little effect on the labor, 15 grains may be 
given every twenty minutes, for three doses ; the patient becomes 
drowsy, dozes, and wakes up as each contraction commences. 
Rarely is a fourth dose required. It does not interfere with the 
use of chloroform, but of that less will be required. It is a very 
valuable aid in the management of labor. 

Chloroform should only be given during the pains, and never 
to unconsciousness. Watch its effects : if the pains lessen in force 
and frequency, stop its inhalation, beginning again when the 
pains are stronger. It is believed that the addition of about one- 
third absolute alcohol will increase the stimulating effects and 
diminish its tendency to cause undue relaxation. As the head 
distends the perinaeum, it may be used more freely, and even to 
complete insensibility just before the child is born. 

Ether acts well, and does not relax the uterus, and even seems 
to intensify the pains. 

Bear in mind the tendency of chloroform to produce uterine 



ANiESTHETIQS IN LABOR. 357 

relaxation, and hence take extra precautions against post-partura 
hemorrhage. 

In operative midwifery, complete anaesthesia is required, and 
here the operator should employ the aid of another physician, 
and his undivided attention should be given to the anaesthetic, 
while the operator is otherwise engaged. 

Dr. Robert P. Harris, American editor of Playfair, snys 
that in the United States chloroform is rarely used in midwifery, 
but preferably pure sulphuric el her. After anaesthesia, uterine 
inertia is very apt to follow, and the result is post-partum hem- 
orrhage. 

DR. J. K. BARTLETT, OF WISCONSIN". 

The method of administering anaesthetics, which this prac- 
titioner has found most successful, is as follows (Trans. Wis- 
consin State Med. Soe., 1879) : The anaesthetic should be admin- 
istered at the very moment the pain is first felt to be coming, or 
known to be so by the finger in the vagina; the inhalation rap- 
idly continued until the uterine contraction has reached its 
climax, and then immediately stopped. Inhalations should not 
be used between the pains, though often urgently desired from 
feelings of discomfort, especially when their use has just been 
commenced. He is strongly inclined to the belief that want of 
attention to this rule has led to some disturbances in the regular- 
ity and force of uterine contractions which have been urged 
against anaesthesia. When a case is first seen when labor is quite 
advanced and pain severe, it is best to give at once full inhala- 
tion to the extent of producing quiet, after which its use can be 
continued as before stated. 

DR. FRACHAUD 

Read a paper before the Section of Obstetrics and Gynecology 
of the International Medical Congress, on the 11th of Septem- 
ber, 1878, on anaesthetics in labor. The following are his con- 
clusions : 



358 COMPLICATIONS OF PARTURITION. 

(1) The employment of anaesthetics is to be advised, as a gen- 
eral rule, in natural labor. 

(2) The principal agents employed at present, are ether, chlo- 
roform, amvlene, laudanum, morphine by subcutaneous injection, 
and chloral by the mouth and by enema. 

(3) Chloroform is the one he considered preferable. 

(4) It should be administered according to the method of 
Snow, that is, in small doses at the commencement of each 
pain ; and it should be suspended as soon as the pain has passed. 

(5) It should never be pushed to complete insensibility, but a 
diminution of pain only should be aimed at. 

(6) It is generally advised to administer chloroform only dur- 
ing the period of expulsion ; but in some cases of extreme nerv- 
ousness and agitation, it is better not to await the complete dilata- 
tion of the os. 

(7) Experiment has shown that anaesthetics do not stop either 
the uterine contractions op those of the abdominal muscles, but 
that they lessen the resistance of the perinaeal muscles. 

(8) The employment of anaesthetics has no injurious effect on 
the health of mother or child. 

(9) In lessening to a greater or less degree the sufferings of 
the woman, anaesthetics are of great service to those women who 
dread the pain ; it lessens the probability of their having nerv- 
ous attacks, and hastens their convalescence. 

(10) Anaesthetics are extremely useful to calm the extreme 
agitation and control excitement which labor often causes in 
very nervous women. 

(11) Their employment is indicated in cases of natural labor, 
which is suspended or retarded by the sufferings caused by pre- 
vious disease, or that coming on during the labor, and in cases 
where irregular, and partial contractions occasion great suffering 
without advancing the labor. 

<12) Chloroform should not be employed in natural labor 
without the consent of the woman and her friends. 

M. Courty spoke in high terms of M. Frachaud's paper, and 
stated that he agreed with him in every particular. 



ANESTHETICS IN LABOB. 359 

PEOF. F. CHUECHILL, M. D., DUBLIN. 

In roost obstetric operations, anaesthesia is of value to relax 
the soft parts and moderate uterine action, etc. 

The dose should be administered at each pain, and increased 
when the head is passing the perinseum. The anaesthetic state 
may be kept up for hours without mischief. The best mode is 
by a clean white handkerchief, folded funnel shape, into which a 
drachm and a half of chloroform is poured ; this is placed over 
the mouth and nose, and it is a good plan to let the patient hold 
it herself, as thus deep anaesthesia is prevented. 

C. J. CAMPBELL, M. D., PAEIS, 

Has for years employed chloroform in labor with good results. 

The administration of chloroform in intermittent doses, during 
the second stage of labor, is of undoubted value. Had it no 
other but a moral effect on the patient, even then it would be 
most valuable, inasmuch as it abolishes the dread of coming 
pain, and enables her to enter labor with confidence and tran- 
quillity. But chloroform, without diminishing the force of the 
uterine contraction, relaxes the parturient canal, abolishes the 
sensation of the straining pains which during this period are 
most violent and agonizing, and economizes the mother's strength 
by sparing her the exhaustion consequent upon the extreme ten- 
sion of the nervous system. With regard to post-partum hemor- 
rhage, the danger is infinitesimal, if the chloroform be with- 
drawn at the. conclusion of the second stage. 

M. LUCAS CHAMPIONNIEEE, PAEIS, 

Says (Le Progres Med., 1880,) that he uses chloroform in 
almost every case, but not to complete anaesthesia. Its action 
varies, requiring a larger amount and longer time in some than 
in others. Early in labor a quite small quantity gives great 
relief, and yet the labor goes on rapidly. Later, it requires a 



360 COMPLICATIONS OF PARTURITION. 

greatly increased dose, and the anaesthesia must be more pro- 
found, and must be maintained. When the waters are evacuated 
and the uterus firmly contracted on the child, the resistance is 
greatly increased, and more trouble is experienced in obtaining 
the good results. Here the chloroform may be pushed until 
sleep is induced. This author finds that it never retards labor, 
generally accelerates it, does not cause stupor in the child, and 
the woman has a better convalescnce in every way. He has 
seen no contra-indications to its use in any case. 

PROF. WM. T. LUSK, M. D., NEW YORK, 

In a paper " On the Necessity of Caution in the Use of Chloro- 
form During Labor," states the following propositions : 

I. Deep anaesthesia, carried to the point of complete abolition 
of consciousness, in some cases weakens uterine action, and some- 
times suspends it altogether. 

II. Chloroform, even when given in the usual obstetrical 
fashion, namely, in small doses, during the pains only, and after 
the commencement of the second stage, may, in exceptional 
cases, so far weaken uterine action as to create the necessity for 
resorting to ergot or forceps. 

III. Patients in labor do not enjoy any absolute immunity 
from the pernicious effects of chloroform. 

IV. Chloroform should not be given in the third stage of 
labor. The relative safety of chloroform in parturition ceases 
with the birtli of the child. 

V. The more remote influence of large doses of chloroform 
during labor upon the puerperal state, is a subject that calls for 
further investigation and inquiry. 

With these five propositions he is prepared to close his indict- 
ment against chloroform in midwifery. It is not a formidable 
one, and need not deter from its cautious employment. But the 
sense of possible danger which governed its use in the hands of 
those to whom we owe its introduction into practice, has been 
replaced by an overweening confidence. 



ANESTHESIA IN LABOR. 361 

PROF. R. BARTHOLOW, M. D., PHILADELPHIA, 

Says when labor is of short duration, and not excessively pain- 
ful, anaesthetics are not to be used. But when the labor is pro- 
tracted and suffering great, they favor progress, and prevent 
exhaustion and uterine inertia. Caution is required with primi- 
para. Inhalation should not begin till the close of the first 
stage, unless there are " nagging pains," and only during a pain. 
The effect must be watched, and the inhalation stopped if the 
pulse fails, the respiration becomes short, and the pains lose effi- 
ciency. Complete unconsciousness is not necessary. 

In instrumental delivery, anaesthesia is important; it facili- 
tates the operation, and prevents shock. It must be carried so 
far as to ensure quietude of the patient, but not complete mus- 
cular resolution. In turning, chloroform narcosis must be deep 
enough to suspend uterine contraction. 

KESUME OF EEMEDIES. 

Alcohol. In default of other anaesthetics, a full dose of whiskey 
or other spirits is a popular obtunder of pain. By 
some obstetricians a mixture is used containing alcohol, 
as that proposed by the Medico-Chirurgical Society of 
London. 

309. R. Alcoholis, # 1 part. 

Chloroformi, 2 " 

Etheris sulph., 3 " M. 

Chloral has been suggested, but its absorption is slow and its 
results uncertain. Injecting it into the veins, after the 
method of Dr. Ore, of Bordeaux, is said to be dan- 
gerous. Playfair prefers chloral to chloroform ; he 
gives gr. xv. at a dose, and repeats in twenty minutes, 
if necessary. Dr. A. F. Watkins (Amer. Practitioner. 
March, 1880,) has derived great advantage from fifteen 
to twenty grains chloral in cases of rigidity and spasm 
of the cervix. The dose may be repeated every twenty 
minutes as required. 



362 COMPLICATIONS OF PARTURITION. 

Chloroform. Simpson recommends chloroform to be used in 
labor, by laying a single fold of a han kerchief over 
the nose and mouth, and dropping the anaesthetic upon 
it, a single drop at a time. In this way it becomes 
thoroughly mixed with air, and is entirely safe. Drs. 
J. Ringer, Playfair, and others, believe that chlo- 
roform weakens uterine contraction. According to a 
recent writer in La Presse Medicate, chloroform acts 
more vigorously and persistently'upon the retractility 
than upon the contractility of the womb. To secure 
this action, prolonged inhalations, rather than complete 
anaesthesia, are desiderated. The contraction of the 
abdominal muscles is more diminished by the chloro- 
form than uterine contraction is. But whilst both 
these effects of this anaesthetic are in proportion to the 
intensity of the anaesthesia, they disappear rapidly, in- 
deed, almost instantaneously, on the cessation of the 
inhalation, whilst the diminution of uterine retractility 
continues longer. Dr. Gehrung, of St. Louis, thinks 
that the poisonous action of chloroform is intensified 
by ergot, both being cerebral anaemiants. 

Ether. Pure, well- washed, sulphuric ether, is claimed by many 
to combine more in its favor as an anaesthetic in labor 
than any other agent. But, as Dr. R. P. Harris 
points out, (notes to Playfair's Midwifery,) only in 
exceptional cases does it act satisfactorily. In many it 
induces intoxication and excitement, and diminishes or 
stops the expulsive efforts, and leads to uterine inertia 
and consequent post- part um hemorrhage. Its admin- 
istration should be preceded by a small dose of brandy, 
to prevent gastric disturbance. 

Hypnotism or Mesmerism. This artificial condition of anaesthe- 
sia has been induced to blunt the pains of labor, and, 
it is stated, with complete success. A case was re- 
corded by Dr. W. B. Fahnestock, in the Boston 
Medical and Surgical Journal, vol. XXXV., No. 10, 
1846, in which a woman was delivered of a full-grown, 
healthy child, while in a state of "artificial somnam- 
bulism," without feeling a pain or interfering with the 
natural contractions of the uterus. In a work pub- 
lished later by the same writer, [Artificial Somnam- 
bulism, p. 316, 1869,) he states that in many other 



ANAESTHETICS IN LABOR. 363 

cases lie has used the same means with equally satis- 
factory results. 

Morphia, The hypodermic injection of morphia has. been found 
to arrest uterine contraction, and is therefore not 
adapted to labor. 

Nitrous O.vide, sl safe and agreeable anaesthetic, produces an in- 
fluence of too short duration to be conveniently em- 
ployed in obstetrics. 



364 COMPLICATIONS OP PAETUEITION. 



ANTISEPTICS IN LABOR. 

Enlightened obstetricians are now fully convinced that a 
puerperal woman is in the condition of a patient with a large 
open wound, and is subject to all the risks of poisoning from 
septic materials which attend such cases. It is doubtful if puer- 
peral fever is anything else than one of the forms of septicaemia ; 
hence it becomes the duty of the obstetrician to exercise the 
same precautions against putrid injection at child-birth which 
the surgeon employs in a capital operation. These measures, as 
recently laid down by Fkitsch, (translated by Dr. J. W. 
Elliot,) are as follows : 

" As a prophylactic measure, at the beginning of labor, the 
patient should have a hip-bath, the hair should be cut from the 
genitals, the vagina and vulva should be washed with soap and 
disinfected with carbolic acid. All the linen, etc., should be 
perfectly clean. Next, the hands of the doctor and nurse should 
be absolutely clean. As many of the instruments as possible 
should be new, at least clean beyond a doubt. No one can be 
perfectly sure that some particles of dirt are not still lodged 
about the finger-nails or in the folds of the skin. I therefore 
propose for students or doctors who have been at work on putrid 
material, or if you like for ordinary use, that they use while ex- 
amining a thin rubber or gold-beater'e kin glove, which having 
a smooth surface can be made perfectly clean. During labor 
every examination should be preceded by a vaginal injection of 
three per cent, carbolic acid to prevent the examining finger 
from carrying germs lodged at the vulva, or in the vagina, up 
to the uterus, which is about to be more or less lacerated. 
Examinations should be made as seldom as possible, and manip- 
ulation with the os uteri or forcible attempts to reach a fonta- 
nelle are unpardonable. After a normal delivery the vagina 
should immediately be washed out with three per cent, carbolic 
acid, and these injections should be continued twice or three 



ANTISEPTICS IX LABOR. 365 

times a day, according to the foulness of the lochia, for 
nine or ten days, in order to wash away the lochia which stag- 
nate just behind the fourchette, if the patient is in the horizontal 
position. 

"The spray has been and is somewhat used just as the head 
appears. After delivery the uterus and genitals should be con- 
sidered as a deep and important wound, which may heal by first 
intention, or in which the secretions may stagnate, become putrid, 
and be absorbed. If the temperature rises to 103° F., and no 
trouble with the nipples or other abnormal condition be present, 
then it is to be supposed that the patient has been infected, and 
the whole generative tract to the fundus uteri should be washed 
out with five per cent, carbolic acid. An irrigator or fountain 
syringe will be found more convenient and much safer than any 
other kind of syringe. 

"An English elastic catheter is convenient to pass into the 
nterus, and should always be held between two fingers spread 
apart, to secure a free outlet for the fluids injected. A new 
catheter .should be used for each case. 

"During the delivery of a macerated foetus, and when meco- 
nium or stinking water has come away, carbolic vaginal injections 
should be repeated every half hour, and after delivery the whole 
genital tract should be washed out with five per cent, carbolic. 

" When part of the membranes are retained and there is no 
hemorrhage, some authorities hold that they should immediately 
be removed to prevent the danger of infection, while others 
maintain that there is more danger of infection from introducing 
the hand or curette than from leaving the membranes and con- 
stantly washing out with carbolic acid. 

" Even after the temperature has been high for some days and 
the abdomen is already tympanitic a thorough washing out of 
the uterus with a disinfectant is often followed by an unexpected 
change for the. better. Although this treatment will not save a 
patient after septicaemia is fairly established, yet the results are 
often astonishingly good in cases apparently far advanced. It is 
certain that by the local treatment we can in many cases stop the 



366 COMPLICATIOXS OF PARTURITION. 

process, and in others its course is at least rendered milder. 
When the secretions are inclined to be retained a drainage tube 
may be left permanently in the uterus, and washed out every 
two hours, or oftener. In severe cases constant irrigation of the 
uterus is of value. To accomplish this the patient is placed on 
a rubber bed-pan, with a tube in the bottom to empty it; a 
double-current catheter or simply a drainage tube is passed to 
the fundus uteri, and held in place by packing the vagina with 
carbolic gauze. The fluid is in an irrigator, and the flow can be 
regulated according to circumstances. If the fluid be kept cold 
by ice we get the additional benefit of the cold to reduce tem- 
perature. The uterus lies so deep in the middle of the body 
that this is very efficacious." 

It must, indeed, be said that perhaps the most important im- 
provement in obstetrics has been effected by the introduction of 
antiseptic methods. It has been correctly observed that in both 
obstetrics and gynecology the conditions in which putrefactive 
changes are met with are found to exist in a great number of 
cases. The puerperal state presents a variety of conditions which 
lead to septic absorption if not corrected by the proper employ- 
ment of antiseptics. After child-birth the uterus and vagina 
present lesions of continuity through which septic matter brought 
into contact with them may be readily absorbed. The interior 
of the uterus has been barred at the placental site, its vessels are 
open, and through this denuded surface septic matter may be 
readily introduced. Other sites of absorption are also to be 
found. How often do we meet with cases of lacerated cervix, 
abrasions or lacerations of the vagina, fourchette or perineum, 
retained portions of plaeenta, or blood clots left to undergo ab- 
sorption or decomposition ? In all such conditions we find the 
strongest indications for the use of antiseptics. 

As a general rule it may be laid down that all operations about 
the vagina should be preceded by cutting the hair, a hip-bath, a 
thorough washing of vagina and vulva with soap and carbolic. 
Closing a ruptured perinaeuni is often done under carbolic spray. 



ANTISEPTICS IN LABOR. 367 

Schroeder and Martin, of Berlin, and others, do all the 
operations about the vagina under a constant stream of carbol- 
ized water. An irrigator being filled with a two per cent, solu- 
tion of carbolic acid, one of the assistants directs the tube so that 
the wound is kept protected from the air ; a rubber sheet under 
the patient is gathered at the bottom near the floor, and conducts 
the fluid to a receptacle. 

Prof. Stadfeldt, of Copenhagen, (Centralhlatt fur Gyne- 
cologies Xo. 7, 1880,) maintains that not only the mortality 
but the morbility of the patients is diminished by the antiseptic 
precautions. The method adopted by him is methodical washing 
out of the vagina before delivery, the application of carbolic 
vapor spray during the delivery, and intra-uterine injections 
with carbolic lotion after delivery. He expresses his astonish- 
ment that the application of carbolic spray has found so little 
acceptance in lying-in institutions, stating that in the Copenhagen 
Maternity it has been four years in use for every labor, without 
having caused any injurious results to mother or child. He 
states, also, that its application causes so little trouble that he 
cannot see why a method so reasonable for a lying-in institution 
should be summarily pushed aside. The spray must be com- 
menced from the moment when the parts of the child begin to 
show themselves at the vulva until any tears which may have 
occurred during the delivery in the vulva are united by suture, 
and the genital opening is covered with a layer of prepared jute. 
The intra-uterine washings after delivery have been found spe- 
cially beneficial under certain conditions, although he has only 
used a three per cent, solution, but in large quantity. He has 
never observed any evil results from these injections in hundreds 
of cases. 

In the Obstetric Hospital of Prague, the antiseptic method is 
rigidly observed under the directions of Prof. B. Von Weber. 
Every physician, student and midwife is supplied with a two per 
cent, solution of carbolic acid, permanganate of potassa, soap, 
nail-brush and scissors, and before entering a ward must wash 



368 COMPLICATIONS OF PAETURITION. 

the hands in soap and water, use the brush, and then the disin- 
fecting fluid. ' 

Near the end of pregnancy, if there be much leucorrhceal dis- 
charge, if it be foetid, or if the patient be feverish, a two per 
cent, vaginal injection is cautiously given twice a day. 

A woman taken in labor is put on a bed which lias been care- 
fully cleaned and purified. Her hands and nails are thoroughly 
cleaned, and they, as well as the genital organs and lower parts 
of the body, are washed with a two per cent, solution of carbolic 
acid. During the course of labor, after the membranes burst, a 
three per cent, solution is injected into the vagina every two 
hours, especially where the amniotic fluid is foetid, where the 
child is known to be dead, where the membranes have burst and 
the head not yet engaged in the pelvic cavity, where the patient 
is feverish, where the presentation is abnormal, where the patient 
has come from the general hospital, or where the placenta is 
retained. When once the perinseum begins to be strained, two 
hand sprays are brought into use and continue to play till the 
placenta has been removed. For the first three days the vagina 
is washed out three times a day, and afterwards twice a day till 
the lochial discharge ceases. If it at any time becomes putrid, a 
three per cent, solution is used every three hours. In all cases 
where instrumental or more than ordinary manual interference 
is necessary, the steam spray is used. The lochial discharge is 
received on napkins, which are rendered antiseptic before being 
applied, or on carbolized cotton-wool, which is afterwards burned. 
Further, three per cent, intra-uterine injections are given where 
there has been any special manual or instrumental interference, 
where the labor has been protracted, where the foetus has been 
dead, where gas or putrid amniotic fluid has passed from the 
uterus, where the temperature has risen, and where delivery has 
taken place on the street. 

In the following classes of cases, intra-uterine injections of 
three to five per cent, carbolic water, or one to three chlorine water 
are used, viz., when the temperature is raised and where there is a 
suspicion of infection, where shivering takes place, and where 



ANTISEPTICS IN LABOK. 369 

the locliial discharge becomes foetid. The conditions which are 
held to contra-indicate intra-uterine injections are spasmodic con- 
traction of the cervix uteri, or in the later days of the puer- 
periurn, complete involution of the vaginal portion, para or per- 
imetritis, deep lesions of the cervix, or rupture of the uterus. 

It is, of course, difficult to carry out. in private practice 
the full details of the antiseptic method as practiced in hos- 
pitals. But a modified and valuable form of it is not difficult 
of application. One such is recommended by Dr. William L. 
Reid, physician, accoucheur to the Western Infirmary, Glas- 
gow. (Glasgow Medical Journal, June 1881.) It is as follows : 

Let every labor-expectant provide herself with a two-ounce bot^ 
tie of 1 to 20 carbolic oil and same quantity of carbolic glycerine. 
When labor sets in and a vaginal examination is to be made, let 
the practitioner oil his whole hand, after having washed it 
thoroughly and passed it through a 1 to 30 watery solution 
made by reducing the carbolic glycerine. Let the carbolized oil 
be used in this way every time an examination is made. This 
would serve two good purposes — less vaginal mucus would be 
removed by the finger, and a film of carbolized oil would be 
left to prevent septic mischief in the canal. After the labor is 
over, the external genitals are to be -bathed by the nurse with a 
warm 1 to 20 solution, and a napkin applied, on the face of 
which is laid a piece of lint damped with the oil. This bathing 
and dressing to be kept up for at least a week. These precau- 
tions would do away greatly with the risk of infection, and yet 
would not involve unreasonable trouble on the part of the at- 
tendants. 

In the case of a woman delivered of a dead child, where the 
placenta and discharges are foul, it is desirable to wash out the 
vagina twice a day with a pint of warm carbolized water, using 
a syringe with a metal or vulcanite vaginal point, which pos- 
sesses only lateral exit holes. This would prevent decaying ma- 
terial from adhering, if the point be not too old, properly washed 
and kept in a carbolic solution. None of the fluid could be 

24 



370 COMPLICATIONS OF PARTURITION. 

forcibly and dangerously injected into the uterus even with only 
very moderate care in the use of the instrument. 

In simple forceps cases, if no previous vaginal examination has 
been made with the unprotected fingers, it is unnecessary to wash 
out the vagina, either before or after the operation, but simply 
to freely carbolize the hands, instruments, and napkins used. It 
is not advisable to wash out the vagina before the operation, be- 
cause it deprives it of its natural and valuable lubricating mucus, 
and because, presumably, no air has had access to it; nor after- 
wards, because the strongly carbolized oil will serve the purpose 
for some hours. But, on the other hand, if there has already 
been much vaginal manipulation, it is desirable to begin by 
washing it out with carbolic water, and then lubricating it freely 
with the oil. After every case of operative interference, the 
vagina should be washed out twice daily for a week, and carbol- 
ized lint, gauze, a sanitary towel, or some such dressing applied 
to the vulva. 

Where either bipolar or ordinary podalic version is practiced, 
or where there is any such often repeated manipulation as is in- 
volved in the removal of the cranial bones, and in embryulcia, 
the spray should be used as well as the oil, else the frequent in- 
troduction of a little air would be pretty certain to lead to decom- 
position of the uterine fluids. 

No vaginal examination should be made without the use of 
an antiseptic ointment. The following is recommended by Dr. 
Reid: 

antiseptic lubricating ointment. 



310. R . Pure soft soap, % iij. 

Glycerine, *^j. 

Carbolic acid, crystals, grs. ixx. 

Oil of bergamot, q. s. M. 

Apply after thoroughly cleansing the hands or instruments. 



Mr. Arthur Richardson, writing to the Lancet, October 
30th, 1880, prefers the following lubricator : 



ANTISEPTICS IN LABOR. 371 

311. R. Castor oil, Jvrj. 

Carbolic acid, ^j. M. 

Use as above. 



PROF. ZWEIFEL, ERLANGEN. 

In the Berliner Klin. Wochenschrift, No. 1, 1878, he alludes 
to the plans of several authorities : Bischoff, of Basle; gave a 
bath at the outset of labor, washing out the vagina with a two 
per cent, carbolized lotion, anointing the fingers of the attendant 
with a ten per cent, lotion at every examination, previously dis- 
infecting the hands by washing in carbolized water. When the 
hand must be passed within the uterus, or if the foetus was well 
decomposed, the cavity was irrigated well with the lotion, and 
the injections were continued for thirteen days after delivery. 
After labor, any wound was touched with a ten per cent, lotion. 
A pad of wadding, soaked in carbolized oil, one part to ten, was 
placed at the opening of the vagina, and frequently renewed. 

H. Fehling, at Leipsic, applied salicylic acid and starch, 
one part to five, to all wounds, and syringed the vagina several 
times a day, in case of foetid discharge, with a salicylic lotion. 

ScHUCKLiNGr employed at the close of labor a carbolized lotion 
of five per cent., to irrigate the parts. 

Zweifel's own method is partly the use of antiseptic measures, 
and partly adoption of the most scrupulous cleanliness in connec- 
tion with the surroundings of the puerperal woman. All vaginal 
examinations during pregnancy are made only after careful wash- 
ing of the hands and smearing with carbolic oil, the vagina being 
further washed out afterwards in some cases with five per cent, 
carbolic solution. The reason for these precautions is the possi- 
bility of infectious matter being introduced into the vagina pre- 
vious to labor, of its lying there and being sucked up into the 
uterus after the expulsion of the foetus. 

The rooms and beds destined for the use of the lying-in, are 
carefully disinfected by burning sulphur in them in fire-proof 
vessels, allowing about four grammes of sulphur to each cubic 
metre of space. The bedclothes are spread out so as to expose 



372 COMPLICATIONS OF PARTURITION. 

as large a surface as possible to the fumes, which, after a few 
hours, are allowed to escape by opening the windows. 

After each labor in which the hand has been introduced into 
the uterus, or where air has gained entrance to it, or gaseous 
decomposition occurred in it, the uterus is washed out with sev- 
eral litres of fresh water. 

Since almost all the cases of puerperal fever are found to be 
complicated either with ruptured perinseum, small rents in the 
vagina and vulva, or with the introduction of air into the uterus 
during some operation, the greatest care is bestowed on all ex- 
ternal wounds, to which Fehling's mixture of salicylic acid and 
starch is applied with the best results. Careful examination of 
the external genitals day by day, and the use of the thermometer, 
are also rigorously attended to. 

Tar-water is maintained by Dr. Joseph Eve Allen, of Au- 
gusta, Georgia, [Atlanta. Med. and Surg. Jouanal, Oct., 1880,) 
to be a more valuable antiseptic in midwifery than any other 
known to us. He claims that the advantages which tar-water has 
over carbolic acid, chloride soda, thymol and other antiseptics, 
and which fit it especially for use during confinement, are : 1st. 
It is a perfect antiseptic and disinfectant, while its odor is pleas- 
ant and agreeable, and such as not to offend the most fastidious. 
2d. The oily and resinous principles which it contains exert a 
healing action upon the genital lesions, and suppuration is pre- 
vented. 3d. The ease with which tar-water can be obtained, and 
its great cheapness, places it within the reach of the poorest 
people. Tar-water is to be used as a vaginal wash three times 
daily, during the lying-in period, and the cloths used to protect 
the vulva and receive the discharges should be moistened with 
it. It may also be employed, should occasion demand, as a wash 
for the uterine cavity, 

ANTISEPTIC UTERIXE POST-PARTUM INJECTIONS. 

As is mentioned above, these injections are recommended by 
some after delivery, in every case ; by others, only when there is 



ANTISEPTICS IN LABOR. 373 

especial cause to fear septic contamination. Schroeder, of 
Berlin, has used strong a solution as of carbolic acid, as 5 per 
cent. But later observers are convinced that this is attended 
with risk. 

Dr. Hofmeir, of Berlin, thus speaks on this subject : " It 
has of late been advised, in the prophylaxis of puerperal fever, 
to irrigate the vagina, cervix, and uterus in all cases, with a two 
per cent, solution of carbolic acid. I wish to show the not incon- 
siderable danger of this method, resulting, in my opinion, from 
the necessitv of brincnn^ hand and instruments in direct contact 
with large raw surfaces; besides, we have not 'the conditions so 
completely under control that we can guarantee the absolute 
cleanliness of instruments, &c. Of two hundred and sixty nor- 
mal cases of recently-delivered women whose uterus I injected, 
forty-two became ill with inflammatory affections of the genital 
tract, or 16 per cent. Of two hundred and forty-nine not so 
treated, nineteen became ill, or 8 per cent. Of the first series, 
eight were dangerously ill ; of the latter, only one. These stat- 
istics are serious. The circumstances are, however, considerably 
altered when, during the birth, gangrene, decomposition, and 
formation of gas in the uterus, and, subsequently, fever develop 
themselves; when we consider how fatal is this condition under 
an expectant treatment, according to Standes' statistics — deaths, 
50 per cent. ; illness, 57 per cent. ; undisturbed recovery, 43 per 
cent. We must seek to remove decomposing masses, or at least, to 
make them innocuous, and for this purpose a five per cent, solution 
is required." 

The dangers likely to accrue from such injections are — 1. Se- 
vere pains and convulsions from the shock of the uterine injec- 
tion being present, even where the antiseptic used was only one 
per cent, in strength, so that it could not be the cause of the 
alarming condition. 2. Over-distention of the uterus may also 
occur, and this leads to severe pain, and may induce inflamma- 
mation. Another danger (3) is the possibility of infecting a 



374 COMPLICATIONS OF PARTURITION. 

patient with a syringe not thoroughly cleansed, and, to obviate 
this, an ordinary double catheter of vulcanite is recommended. 
In a recent discussion Dr. Atthill pointed out the great 
value of these injections, and expressed his opinion that a one 
per cent, solution of carbolic acid used twenty-four hours after 
delivery is quite safe. 



PLACENTA PB^VIA. 375 

PLACENTA PREVIA. 

DR. ISAAC E. TAYLOR, NEW YORK. 

This author (Trans, of the Amer. Gynecol. Soc, 1878,) remarks 
that the methods which have been adopted in the management 
of placenta prsevia are : 

1. The tampon. 

2. Version, internal or external, or both. 

3. Partial circular detachment of the placenta. (Barnes.) 

4. Complete detachment. (Simpson.) 

5. Lateral detachment — usually adopted. 

6. The forceps. 

7. Induction of premature labor. 

As a tampon our author prefers the ordinary surgical bandage. 
After the external parts have been lubricated, the bandage is 
introduced into the vagina and packed firmly and securely, one 
end being allowed to hang from the vulva, so that by one pull 
the whole tampon may be removed. 

The tampon not only arrests hemorrhage, but stimulates 
uterine action and paves the way for version or the forceps. Er- 
got may be given carefully, and according to the nature of the 
case, to increase the uterine action after the tampon has been in- 
serted. After from one to three hours the tampon may be 
removed, and, as a rule, the patient can be at once delivered. 

The advantages of early version are considerable, and the fears 
about it which have been expressed by some writers are ground- 
less. In the majority of cases the use of the forceps is not neces- 
sary. The induction of premature labor is called for in a small 
number of cases. 



376 COMPLICATIONS OF PARTURITION. 

DR. ENOCH W. KING, OF NEW ALBANY, IND., 

Has published the analysis of a large number of case of placenta 
prsevia, treated by various means. (Amer. Jour, of Obstetrics, 
Oct., 1880.) 

In regard to ergot, there appears to be little doubt that it ex- 
ercises a favorable influence if administered in suitable cases, 
and at the right time. This means that we should be guided in 
its administration by the same rules as in ordinary labor ; that 
is, until there is a demand and an opportunity for expulsive, 
not dilating pains. It is especially dangerous to the child when 
there is a complete presentation of the placenta, thus forming 
an obstruction to the delivery. 

Completely detaching the placenta usually controls the hem- 
orrhage, but is almost invariably fatal to the child. Evacuation 
of the liquor amnii cannot be recommended, on account of the 
danger resulting from occult hemorrhage. The tampon is of 
doubtful efficiency, and very certainly increases the risk in many 
cases to both mother and child from intra-uterine hemorrhage. 
The use of the forceps as a means for hastening delivery has 
been found wanting. The most satisfactory results have been 
from version, performed as early as possible, together with the 
administration of ergot at the appropriate moment, to secure effi- 
cient uterine contractions after the contents of the womb have 
been expelled. 

DR. JOHN HAUENSTEIN, BUFFALO 

Concludes the treatment of a case as follows {Buff. Med. and 
Surg. Jour., Oct., 1875): The vagina, a yielding cylinder, can- 
not be plugged with an unyielding tampon ; hence he uses a 
colpeurynter with a moderately thick layer of absorbent cotton 
drawn over it, and large enough to cover it when distended with 
water. To prevent post-partum hemorrhage, he applies a plug 
saturated with subsulphate of iron, at the same time keeping up 
the contraction of the uterus. 



PLACENTA PREVIA. 377 

DE. J. E. NUNN, SAVANNAH, GA ., 

Jleports a successful case treated by persulphate of iron, in the 
American Journal of Obstetrics, 1879. He uses it as follows : 
He found the pains had entirely ceased, the vagina was filled 
with clots, the os dilated sufficiently to admit the finger, by which 
the placenta could be easily detected, and the warm blood could 
be distinctly felt flowing through the os. Cleaning out the clots, 
a speculum was introduced, and the liquor ferri persulphatis was 
applied to the bleeding surface by means of a cotton swab passed 
through the os. The hemorrhage ceased instantly and abso- 
lutely, and the speculum was retained in place about fifteen 
minutes, to see that bleeding did not recur. Stimulants and 
ergot were then given freely, and a pledget of cotton saturated 
with styptic was left in the os, and sustained in place by a very 
slight tampon of cotton merely sufficient to hold it in place until 
contractions and the os was sufficiently often to admit of version. 
M. Chanteetjil, (Union Med., July 15th, 1879,) in anae- 
mia after hemorrhage from vicious insertion of placenta, uses 
injections of sulphuric ether (4 grammes) into the subcutaneous 
cellular tissue. Later, one or more such injections of brandy. 
The heat is re-established, and the patient is re-animated. 



378 COMPLICATIONS OF PARTURITION. 

TEDIOUS LABOR. 

EIGID OS AND ATONY OF UTEKUS. 
ALBERT H. SMITH, M. D., PHILADELPHIA, 

In a paper read before the Philadelphia County Medical Society, 
(Medical and Surgical Reporter, August 11th and 18th, 1877,) 
says the causes of delay may be divided into classes: Rigidity 
of the os or absence of the dilatory force, or real and apparent 
rigidity. Spasmodic contraction of the os is a neurosis, and for 
its relief we require such means as quiet nervous excitement, 
allay sensibility, diminish the activity of the circulation, and con- 
trol the local congestions. First of these is opium. Acts promptly, 
without danger, and never contra-indicated. A suppository of 
one-half a grain to a grain of watery extract, or its equivalent in 
morphia, powdered opium, or an enema of laudanum, or the 
hypodermic; or in case of much fever, morphia with digitalis 
and diaphoretics, will be certain of good results. 

Ether or chloroform may give the same, but are not so safe, 
and diminish the force of the contractions, and may cause inertia 
uteri and hemorrhage. 

Passive rigidity, that is, a want of distensibility, must be met 
by the douche of hot water, 105° to 110°, injecting a quart at a 
time by the syringe against the os and cervix, and repeating 
every hour or two. Traction by the finger upon the anterior lip 
is here of great value, though not when there is spasm. When 
the membranes are not ruptured, care should be taken not to do 
this. The India-rubber bags are valuable dilators — that of 
Bratjn, of Vienna, or better, the fiddle-shaped bags of Barnes ; 
they should be filled with warm water until fully expanded. After 
dilatation has given room, apply the forceps within the lips, and 
thus we gain an additional dilating power. There can be no 
more risk to the tissues than by the passage of the head without 



TEDIOUS LABOE. 379 

them. During each contraction the forceps may be gently drawn 
upon. 

Incision is justifiable only under extremely rare conditions. 

In delay from absence of the dilating wedge, which is the most 
common cause of delay, this is often the result of inertia, and 
may be met by abdominal frictions, diffusible stimulants, ginger, 
balm, mint, or other hot teas, hot and cold douche, etc. The 
best of all is the bisulphate of quinia — say 15 grains in one dose. 

When the preternatural distention of the amniotic sac stretches 
too greatly the uterine fibres, its rupture will generally speedily 
correct the evil. Irregular contractions are best met by the quiet 
and rest of opium, anaesthetics, chloral, etc. 

Premature labor would also cause delay, and require opium or 
chloral for relief. 

In cases of disproportion of the head and pelvis, the one ab- 
normally large, or the other small, the only remedy is to carry 
the forceps within the os, and the accomplishment of the delivery 
as above detailed. 



W. H. LONG, M. D., LOUISVILLE, KY., 

Speaks of viscum album or mistletoe as an oxytocic. He has used 
it for ten years. It acts with more certainty and promptness 
than ergot, and does not cause continuous or chronic contractions. 
The fluid extract is preferable, in doses of a drachm, repeated 
every twenty minutes until the desired effect is induced. The 
infusion is made by taking 2 oz. of the dried, or 4 oz. of the 
green leaves, pouring over them one pint of boiling water, cov- 
ering until cool enough to drink. Dose, two to four ounces, 
repeated in twenty minutes, if necessary. He has seen excellent 
results follow its use in post-partum hemorrhage and in menor- 
rhagia. 

J. H. BENNETT, M. D., OF OHIO, 

Proposes (Detroit Lancet) to facilitate and shorten labor by giving a 
hypodermic injection of morphia, gr. J. When rest has restored the 



380 COMPLICATIONS OF PARTURITION. 

nervous energy, he places the patient on her back, the thighs 
flexed, the shoulders bolstered up, the smaller or lumbar portion 
of the spiue down, so as to form a curve, the convexity of which 
is down; thus the axes of the two straits form a continuous 
curve. Labor commencing, the os is gently pulled forward by 
the index-finger, causing dilatation, at the same time pressing the 
fundus gently upwards and back so as to bring the child in 
proper relation with the lower strait. During the passage of the 
head into the lower strait, he continually draws'forward the an- 
terior lip of the os, at the same time pressing the anterior portion 
of the os back under the os pubis, with other soft tissues that 
protrude with the anterior portion of the os and neck, which nar- 
rows the antero-posterior diameter. As the os dilates under the 
forward and lateral pressure, during the interval of pain, the 
anterior lip of the os passes back under the arch of the pubis, 
and finally over the occiput ; thus increasing the antero-posterior 
diameter and facilitating very much the passage of the head, also 
saving the contusion of the urethra, which so frequently occurs. 

After this stage he protects the urethra and tissues adjacent, 
by pressing upon the occiput forwards and downwards with the 
digital and middle fingers, each side of the urethra, until it passes 
from under the os pubis; thus avoiding the necessity of being 
called to use the catheter, also preventing one of the causes of 
vesico-vaginal fistula, and lessening the danger of laceration of 
the perinseum by the occiput rising in front of the os pubis, 
sooner than it would if the anterior portion of os with folds of 
the vagina and other soft parts protruded in front of the head. 
In this way the pressure on the perinseum is lessened. 

During the above management, if the patient is weak-and the 
pains feeble, to induce instinctive action of the uterus and abdom- 
inal muscles, pass the middle and index-fingers of the right hand 
(the palmar surface down) back with gentle pressure downwards 
against the perinseum and vulva, producing the sensation of ad- 
vance of the head. 



TEDIOUS LABOE. 381 

HEXEY L. HORTON, M. D., NEW YORK, 

(Am. Jour. Obst., July, 1878,) states that atropine injected into 
the tissues of the cervix uteri will lessen the pain and shorten 
the duration of the first stage of labor, by overcoming the spastic 
rigidity of that structure. He uses about one- fortieth or fiftieth 
part of a grain of atropia sulphate for each injection. He has had 
manufactured a hypodermic syringe, long needle with a hook- 
curve at the end. "After hooking the anterior lip of the cervix 
with the index-finger of the right hand and drawing it slightly 
forward, he carries the needle along the palmar surface, keeping 
the point pressed quite firmly against it, so as to avoid wounding 
the maternal parts. After carrying its points well within the 
cervix, he raises it from the finger, and by a slight traction, buries 
it somewhat deeply into the muscular structure of that portion 
of the uterus. After discharging its contents, he retains it in 
that position a few moments, in order that the absorption of the 
atropine may be certain to take place/' 

PROF. W. S. PLAYFAIR, M. D., LONDON. 

Where there is feeble or irregular action, a loaded rectum is 
often the cause, and a large enema will generally produce a 
remarkable effect. 

Excessive distention of the uterus is relieved by rupture of the 
membranes. Adherent membranes may be separated by sweep- 
ing the finger or a flexible catheter round within the os. Uterine 
deviations must be corrected by placing the patient on the oppo- 
site side to that towards which the organ points, or when an- 
terior, place her on her back and apply a bandage to prevent the 
organ falling forward. Temporary exhaustion requires rest, as 
by an opiate, as 20 minims of Battley's solution or an enema of 
the same. When pains are irregular, spasmodic and painful, 
chloral is of great value. 

Oxytocics or remedies to increase the force of the pains, are 
borax, cinnamon, quinine, galvanism, and ergot. The latter has 



382 COMPLICATIONS OF PARTURITION. 

serious disadvantages to both mother and child. It is only allow- 
able when the os is fully dilated. 

Manual pressure often produces the most speedy effect. The 
best way is to place the patient on her back at the edge of the 
bed, and spread the palms of the hands on each side of the fundus 
and body of the uterus, and when a pain begins, make firm pres- 
sure down and back in the direction of the outlet ; relax the pres- 
sure when the pain goes off, and resume when a new pain comes. 
The patient need not lie on her back ; pressure may be made in 
the ordinary obstetric position on the left side, the left hand 
spread over the fundus, leaving the right free to note the pro- 
gress per vaginam. This plan is completely at the will of the 
operator, and can be nicely regulated ; it imitates nature, and is 
without risk to child or mother. The pressure must be firm, 
but not rough. The use of the forceps is now becoming the rule 
in place of the exception, to put an end to protracted labor. It 
diminishes in a marked degree infant mortality. There is no 
danger to the mother, but often great danger from a delay in 
their use. 



In rigid os, ansesthetics are required. Chloroform is preferred, 
but chloral is more marked in its effects. When the os seems 
occluded, mechanical means to dilate must be employed, as 
sponge-tents, and the like. Inertia of the uterus may be caused 
by rheumatism, neuralgia, etc. A distended bladder or rectum 
may act mechanically, and in such cases there is generally cramp 
of the lower limbs, and this agony weakens the action of the 
womb. The means of relief here is patent and immediately effi- 
cient. 

Ergot, to increase the activity of the pains, is never perfectly 
safe, and the forceps should, when possible, be preferred. 

ALFRED MEADOWS, M. D., LONDON. 

Tartar emetic will be found of the greatest service in small 



TEDIOUS LABOR. 383 

and frequently-repeated doses, so as to cause nausea, when the 
rigidity readily yields. Sometimes it appears to act better when 
combined with opium, or is facilitated by saline purgatives, as 
where there is gastric derangement, with foul tongue, offensive 
breath, constipation, etc. 

Opium alone is of the utmost value. Chloroform is another 
valuable remedy. Bleeding, in plethoric subjects, requires a full 
stream, to the amount of twelve or sixteen ounces. A vaginal 
pessary — one part gelatin, four of glycerine, made with two or 
more grains of extract of belladonna — soon melts and is absorbed, 
and may aid the dilatation. In certain cases all these fail, and 
we require the artificial dilator, the India-rubber bag. Where 
rigidity is obstinate, and there is fear of uterine rupture, or ex- 
haustion of the patient, the cervix should be incised, not too 
deeply, say from a quarter to half an inch in several directions. 

ARTHUR WIGGLESWORTH, M. D., LIVERPOOL. 

This writer [Obstetric Journal Great Britain and Ireland, 
Sept., 1877,) advances these propositions: An os more or less 
dilated, but rigid with active contractions, is rigidity from 
spasm ; this may arise from direct or indirect causes, but with 
the same results; this condition may be removed by the admin- 
istration of morphia, with the object of relaxing the circular fibres 
without inducing either nausea or exhaustion. The dose must 
be regulated according to physical condition of the patient, the 
amount of rigidity, the condition of the stomach. A nervous, 
excitable temperament requires a smajler dose than a phlegmatic 
one, also if there is much exhaustion. A thick, rigid os, with a 
phlegmatic system, requires a larger dose, or a repetition. If the 
stomach is loaded, a larger dose is required. 

Where rigidity has been long existent, and there is exhaustion 
without relaxation, and a subsidence of uterine action, ergot and 
morphia should be combined. 



384 COMPLICATIONS OF PARTURITION. 

¥11. STEPHENSON, M. D., LONDON, 

In the Obstetric Journal Great Britain and Ireland, Aug., 1878, 
directs the introduction of one or more fingers of the right hand 
within the os, opposite the thyroid foramina in first and second 
positions, and the sacro-iliac junction in the third and fourth, 
and thus to lift or support the head during each pain. His 
design is to effect the extrusion of the occiput through the os, 
securing greater flexion and aiding rotation. It is employed 
after rupture of the membranes, before complete dilation, and 
when the cervix does not yield and recede over the head. 

KESUME OF EEMEDIES. 

Alcohol counteracts the tendency of anaesthetics to weaken ute- 
rine action, and acts as a general stimulant to the mus- 
cular forces in labor. (Dr. D. Morton, Amer. Practi- 
tioner, Dec, 1874.) 

Antimonii et Poiassce Tartras, in tedious labor from rigid os, in 
doses of gr. 1/ 2 q to l/ 12 every fifteen minutes, is an an- 
cient and often efficient method of overcoming spas- 
modic muscular contraction. 

Amyl Nitrite. When the uterus is spasmodically contracted on 
the foetus, Dr. Maury, of New York, believes that 
this agent is a most valuable remedy. 

Atropia is given by Dr. Horton, as above stated, in cases 
where the uterus has become completely or partially 
spasmodically contracted on the foetus, or on a sepa- 
rated placenta, in order to overcome the spasm. Dr. 
Frankel, of Breslau, recommends a hypodermic of 
I/33 of a grain of atropia, and J of a grain of mor- 
phia, with inhalation of chloroform five minutes later. 
The uterus relaxes speedily and yieldingly. There 
need be no fear of post-partum hemorrhage. 

Belladonna, in the form of ointment of the extract, is an agent 
of old renown. 

Carbonis Sulphidum. Milne Edwards and Vavaseau assert 
that a few drops sprinkled on the abdomen of a 
woman in labor, will reawaken uterine contraction. 



TEDIOUS LABOR. 385 

Caulophyllum Thalictroides. At a meeting of the Obstetric Sec- 
tion of the New York Academy of Medicine, Dr. Sell 
related a case as an example of several, in which he 
used the concentrated tincture of caulophyllum, blue 
cohosh or squaw-weed, with the happiest results, as a 
remedy to ward off tedious labor. The remedy was 
especially applicable in those cases in which the woman 
had habitually suffered severely during the first stage 
of labor. As a preparatory remedy in such cases, ifc 
should be administered in twenty-drop doses three 
times a day, for three or four weeks previous to confine- 
ment. 

Cannabis Indiea. Dr. Alex. Christison claims that cannabis 
indica equals ergot, being quicker and more energetic, 
but of shorter duration. 

Chloral acts at times indirectly as an accelerator of parturition. 
Dr. Wm. L. Richardson remarks (Trans. Am. Gyn. 
Soc, vol. I.,) that it seems especially adapted to that 
large class of cases in which the pains occur at very 
short intervals, last but a moment, and are very severe. 
Little progress is made, and the patient suffers intensely, 
and becomes restless and nervous. In such cases the 
administration of chloral is followed by the happiest 
results. The dose may be gr. x.-xx., repeated if called 
for. Dr. T. A. Reamy, of Cincinnati, says that close 
observation has convinced him that no bad effects on 
the child follow the administration of this drug. -(Ob- 
stetric Gazette, November, 1878.) 

Chloroform, administered for its anaesthetic properties, will often 
do away with spasmodic rigidity of the os. 

Cimicifuga Racemosa is alleged by the eclectics to exert some 
ecbolic powers. Cimicifugin is extolled as of great 
value as a substitute for ergot, acting speedily and 
energetically. The contractions, unlike ergot, are not 
powerful and continuous, and hence there is less dan- 
ger to the child. After labor, it allays nervous excite- 
ment and relieves the after-pains, and checks hemor- 
rhage. (Phillips.) 

Cinnamomum has some slight power as a uterine stimulant. 

Ergota. The accelerator of uterine contraction is par excellence 
the ergot of the cereals ; that of rye is usually employed. 
The propriety and rules of its use have been much and 
variously debated. Points generally agreed upon are 



386 COMPLICATIONS OF PARTURITION. 

that it should not be given if there is rigidity of the os, 
nor until the os is dilated or dilatable. The contrac- 
tions it causes are continuous and violent; hence it is 
suited to the third stage only. 

Gelsemium is a valuable remedy in cases of rigid os during labor, 
gtt. v. of the fluid extract every ten minutes until there 
is nausea. 

Ipecacuanha In cases of irregular uterine action, and protracted, 
agonizing, yet insufficient pains,this drug exercises the 
happiest powers, relieving the pain and hastening the 
termination of the labor. The 'dose may be gr. ij. every 
fifteen minutes. It takes effect in about thirty min- 
utes. A very favorite form with some practitioners is 
" Dover's powder " in repeated small doses, combined 
either with ergot or chloral, as occasion demands. 

Lobelia Inflata is asserted by Sctjdder and other eclectics to be 
a specific in rigid os. It probably acts from its nause- 
ating properties. They prescribe : 

312. R . Tinct. lobelia?, f. ^j. 

Aquse, f. !| iv. M. 

A teaspoonful every fifteen minutes. 

Oleum Ricini in small doses, for some time before labor com- 
mences, is said to facilitate it. 

Opium and its alkaloids are of advantage to control the nervous 
restlessness aad exhaustion which supervene in tedious 
labor, and to lessen the spastic rigidity of the os. 
Small quantities, gr. J, of morphia, in camphor- water, 
may be given hourly or half-hourly. Of its employ- 
ment during labor Dr. Lusk says that from a number 
of observations, there is no reason to apprehend any 
direct effect on the child from morphia hypodermically 
administered to the mother during labor. The pro- 
priety of its use, therefore, is to be determined by purely 
obstetric considerations. When given to meet some 
urgent need in the mother, it probably conduces in- 
directly to the welfare of the child. 

Quinia. That sulphate of quinine has a direct power to promote 
normal labor, cannot longer be disputed. Dr. Albert 
H. Smith, after a careful study of the subject, said 
some years ago (Obstet. Jour., June, 1875,) that it 



TEDIOUS LABOR. 387 

"increases the activity of the normal uterine contrac- 
tions) the pains becoming more frequent and more in- 
tense, the expulsive power being greater, while the 
yielding of the circular fibres of the os is more prompt ; 
the contractions maintaining their proper intermittent 
character, the relaxation and rest in the interval being 
complete; showing in this respect an entirely different 
action from the continuous spasmodic contraction caused 
by ergot. * * * It promotes permanent tonic con- 
traction of the uterus after the expulsion of the pla- 
centa. * *• * It diminishes the lochial discharge 
to a normal standard. * * * Its use is followed 
by less after-pains than usual, in a majority of cases. 
* * * Given during parturition, it never disturbs 
the brain or causes its usual unpleasant effects, even in 
patients who at other times are very susceptible to its 
influence." The dose is gr. xv., repeated if necessary. 
Others give gr. viij.-x. 

Sodii Boras has a doubtful claim to being an oxytocic. 

TJstllago Maidis, the ergot of maize, has been recently intro- 
duced. It is not dissimilar from other ergots. 

Viscum Album, the mistletoe, has alleged paturifacient properties. 
(See above.) 

EXTERNAL MEASURES. 

Abdominal Friction is an excellent agent for expediting labor. 
Much force should not be used. The object is by 
gentle friction and pressure to excite uniform and effec- 
tive uterine contractions. 

Dilatation of the os by the finger has been strongly recommended 
by Dr. James Braithwaite, where the rigid os gives 
rise to symptoms of exhaustion. In the method he 
employs, the right index-finger is introduced within 
the os uteri, with its palmar surface toward the sacrum ; 
the left index-finger is then passed, with its palmar 
surface toward the pubes, the left hand crossing over 
the right for this purpose. By gentle pressure in op- 
posite directions the os is readily made to dilate; the 
fingers being hooked within the os, the pressure is also 
made downward, thus very closely resembling the nat- 
ural process. As soon as the os is dilated to the sizd 



388 COMPLICATIONS OF PARTURITION. 

of a five-shilling piece, two fingers of each hand can be 
introduced for manipulating. 

Electricity has been employed as a uterine stimulant, but it has 
proved inconvenient in practice, not easily manageable, 
and not very effective. 

Incision of the os, as a surgical measure, may be resorted to in 
obstinate, and especially in cicatricial rigidity. 

Injections of warm water in the vagina, in properly-chosen cases, 
will accelerate the labor without causing any increase 
of suffering to the mother. The only instrument re- 
quired, besides a bowl of warm water, is a syringe 
fitted with a vaginal tube ; but this apparatus can be 
improved by the addition of a yard of India-rubber 
tubing, three-eighths of an inch in diameter, joined to 
the vaginal tube so as to carry off the water direct 
from the vagina into a receptacle, thus avoiding wet- 
ting the bed. The water should be as warm as the 
patient can comfortably bear, and in practice it is ad- 
visable not to begin with water raised to the full tem- 
perature, but gradually to add boiling water until the 
temperature of about 105° F. has been attained. The 
injection requires to be continued from five to twenty 
minutes, according to circumstances. 

Hip-Baths, as hot as the patient can comfortably bear, will often 
expedite labor, and relieve the patient in the most 
satisfactory manner. 

Venesection, in cases of obstinate spasmodic contractions, is hardly 
ever necessary, now that the means above enumerated 
are within our reach. 



AFTER-PAINS. 389 

AFTER-PAINS. 

DR. JOHN E. RANKING. 

This writer, in a very thorough analysis of the symptoms and 
treatment of after-pains (Edinburgh Medical Journal, July- 
Sept., 1880.) distinguishes between those which are of an expul- 
sive, spasmodic, rheumatic or neuralgic origin. The preventive 
and curative treatment of these differ materially. 

1. Expulsive After-pains. These are usually owing to post- 
partum coagula. Their prevention aims to ensure firm contrac- 
tion which shall last long enough to allow durable thrombi to 
form in the mouths of the uterine vessels, and furthermore so to 
regulate the patient's surroundings that the fall of vascular ten- 
sion which almost invariably succeeds delivery shall not be too 
rapidly disturbed. The object, then, is two-fold — (1) Efficient 
contraction ; (2) Vascular tranquillity. 

Nature's mode of ensuring efficient contraction is, by affording 
a due proportion of rest to the uterine fibre. This may be imi- 
tated, by avoiding all hurry in the management of the later 
stages of labor, especially the third. The placenta must not be 
hurriedly expressed nor withdrawn ; but we must wait until a 
renewed and vigorous throe shows that the organ is ready to 
resume contraction. The hand, after expressing the placenta, 
should continue to grasp the uterus firmly, yet gently, for some 
time ; and the binder should not be applied until we are satisfied 
that the organ has no tendency to relax. 

In some other cases (and these occur most commonly among 
the poorer classes,) in which, either from the history of previous 
labors or from any other circumstance, we have reason to sus- 
pect great want of uterine tone, or when on former occasions we 
have found manual compression insufficient, we have a most power- 
ful ally in ergot 

In most authors there is a want of distinction as to the exact 
conditions to which it is applicable and the period at which it is 



390 COMPLICATIONS OF PAETURITTON". 

indicated. There are, for instance, numbers of persons who 
suffer horrible tortures from after-pains, but to give them ergot 
is only to increase their agony four-fold ; and why ? Simply 
because the pain is not expulsive, but spasmodic, and due not to 
the presence of intra-uterine coagula, but to uterine hyperesthesia. 
Ergot is only useful in those cases where relaxation of uterine 
fibre allows bleeding from the vessels, and then only as a pre- 
ventive. In very obstinate cases the addition of liquor strychnia 
ffyv. is very useful. 

The time at which it is best given next claims notice. It is a 
good rule to give 3j. or 3 ij. when, as far as one can judge, 
delivery will be naturally accomplished in about fifteen minutes. 
By this means, no undue strain can be put upon the maternal 
structures, nor perilous pressure upon the foetus, and persistent 
contraction of the uterine fibre only occurs when no harm is 
possible. 

Its administration after the expulsion of the foetus is not so 
serviceable, even when accompanied by manual compression, 
which should in no case be omitted. The difference may perhaps 
be partially accounted for by the difficulty of maintaining com- 
plete rest. A natural degree of vascular tranquillity is a sine 
qua non of success. In cases where the vascular tension has not 
fallen perceptibly, or has soon risen again in spite of all precau- 
tions, ergot has quite failed in preventing coagulation within the 
uterus. Vascular excitement is too often the result of want of 
care. Thus a patient is perhaps hauled from the foot to the 
head of the bed, or from one side to the other, not to mention 
the vile practice among the poorest of turning back the bed and 
being delivered on the sacking, frequently with all the clothes 
on. The moving which thus becomes necessary cannot be 
effected without raising arterial tension considerably, and at any 
rate quite sufficiently to nullify the firmest uterine contraction. 

Another source of failure is administration of alcoholic stimu- 
lants during or soon after delivery. To ensure the necessary 
vascular tranquillity, we must — (1.) Never allow the patient to 
move herself, nor move her except by gentle and efficient lifting. 



AFTER-PAINS. 391 

(2.) Never, except uDcler absolute necessity, give alcoholic stimu- 
lants during or immediately after labor. The rule, which is so 
often urged in writing about post-partum hemorrhage, never to 
be too hasty in attempts to rally the patient from the faintness 
which is but assisting nature, applies here with equal force. 
(3.) Avoid all occasions of excitement and emotion. 

In cases where it is possible to adopt measures for the im- 
provement of nutrition and tone, both of the uterus and the 
general svstem, either in the intervals between successive impreg- 
nations or during the pregnancy, these should undoubtedly be 
employed. If, however, coagula have formed, our object must, 
of course, be to favor expulsion, and the sooner the better. 
For this purpose the best method, if it can be practiced, is 
digital extraction. If this be impossible, we are driven to the, 
use of anodynes, not only to soothe the pain until the process is 
accomplished, but to assist in relaxing the cervical fibres. Chlo- 
ral in one full dose, or, better, in smaller doses at frequent inter- 
vals, is often effectual; 15 or 20 grains, repeated at intervals of 
about twenty minutes for three times, is a suitable dose. Opium 
has been used from time immemorial ; but the dose required is 
often enormous. Nitrite of amyl would perhaps prove useful, 
as Dr. Barnes has found it instantaneously beneficial in relaxing 
tetanus of the uterus. It must, however, be borne in mind that 
its use soon after delivery has been followed by flooding. Chlo- 
roform has no advantages over chloral. With either of these 
ergot may be given ; but as the distress is due not to insufficient 
action, but to increased resistance, it will be rarely necessary. The 
same remark applies to friction over the uterus. Purgation, espe- 
cially if brisk, is very useful in aiding expulsion of coagula ; and 
of all purgatives, castor-oil, with or without opium, is the best, if 
its use be not contra-indicated by the presence of piles. The 
compound scammony pill is also a very elegant and most effective 
purge. 

2. Spasmodic After-pains. — The condition of the uterine 
fibre upon which these depend appears to be so entirely an ex- 
pression of a general constitutional habit that prevention, in the 



392 COMPLICATIONS OF PARTURITION. 

sense of obviation of the primary cause, is entirely out of the 
question. So closely are they bound up with neuralgic after- 
pains that we may very well consider their treatment together. 
We must, however, make this limitation, that whereas no antece- 
dent treatment will obviate nor apparently mitigate, in any great 
degree, spasmodic pains, proper and well-directed treatment dur- 
ing pregnancy is most effectual in preventing neuralgic pain in 
the uterus after delivery. 

Spasmodic affections of the uterus, as of other organs, though 
often occurring without any apparent cause, are very much in- 
creased by any condition either local or remote, which excites or 
tends to heighten reflex irritability. Thus the increased local 
excitement consequent upon chronic metritis, irritable uterus, 
hyperesthesia during pregnancy, hypogastric pains during preg- 
nancy, a clot in the vagina which impinges upon without invading 
the cervix, may in each case give rise to very great pain. Again, 
retention of urine, or faeces or flatus in the intestines, and espe- 
cially tender or sore nipples, will excite the same trouble. 

Preventive treatment, therefore, consists in taking care that all 
possible causes of irritation, both local and distant, be as far as 
may be removed. Foremost of all stands the precaution that the 
uterus contract efficiently ab initio; for, in persons disposed to 
these pains they are doubly troublesome if the cavity has been 
distended. The best modes of ensuring this are manual com- 
pression, and especially by never allowing the uterus to spend 
its own and the patient's strength in fruitless, unavailing efforts. 
This is to be prevented by judicious use of sedatives in the early 
stages, and by instrumental aid during the later stages of labor. 
The care which is directed to a long and thorough preparation 
of the nipples for the office which they must fulfill will be well 
repaid, and careful regulation of the bowels will also be of ser- 
vice. A suitable dietary is another very efficient means of les- 
sening suffering from these pains. The fact that they are known 
to be habitual should always prompt us to order a very liberal 
diet from the first. Thus many a patient who, upon a light and 
only moderately nutritious diet, is in sleepless agony for four or 



AFTER PAINS. 393 

five days will, if given a chop and a proper amount of her usual 
stimulant within twenty-four hours after delivery, be free of pain 
altogether by the third day. Sleeplessness is not only potent to 
perpetuate these pains, but will sometimes encourage their onset. 
One or two bad nights, especially if combined Avith the regula- 
tion starvation (which is still far too common) or with sore nip- 
ples, will often bring on these pains three or four days after 
delivery, even when they have, up to that time, been absent. 
By means such as these we may hope, if not entirely to avert, 
at least to diminish the suffering which the patient must un- 
dergo. 

Curative Treatment — Premising that, whatever means we may 
adopt for cure, the preventive measures just indicated must in 
all cases form part of the treatment, we pass on to consider the 
various drugs which are more or less useful in different instances. 
Here we are met by the real difficulty of the problem, to which 
we owe such frequent failures. The spasmodic contractions are 
caused directly, at any rate in the greater number, by the ganglia 
which reside within the uterine walls themselves ; and until we 
know of some drug which will control the activity of these, without 
also affecting the whole organism, the medicinal aspect of the 
question must be unsatisfactory. The various drugs which are 
most suitable are, chloral, bromides, morphia, atropia, henbane, 
camphor, cannabis indica, conia, gelseminum, quinine. These 
may be employed both internally or as external applications. It 
is hard to say which is most generally useful, one often succeed- 
ing where another has failed ; but in estimating the value of any 
one of them it is needful to remember that, except in very severe 
cases, the pain usually disappears naturally about the fourth or 
fifth day. Opium and its derivatives should best be avoided, as 
causing disturbance of the general functions. When the pains 
are distinctly spasmodic, great benefit is derived from gelseminum, 
but the dose must be large ( 3j. of tincture.) In some cases dis- 
tressing pains give place to quiet sleep. Conia, in suppositories 
containing one grain, is of great use, repeated every four hours. 
More than two are rarely necessary. The effects of these two 



394 COMPLICATIONS OF PARTURITION. 

drugs are more permanent than that of the others. Where the 
pain is less distinctly spasmodic, but is characterized by constant 
aching and tenderness in the womb, very good results come from 
quinine and hydrobromic acid, with a liniment of aconite, bella- 
donna, and chloroform on spongio-piline or wool covered by 
oiled silk. Very severe pain yields quicker to full doses of 
quinine — four or five grains every four hours, with or without 
belladonna. 

The rectum is the best medium for admiuitsering any drugs 
which are applicable to that method. 

Our aim, if we wish to avoid or mitigate these pains, must be 
to endeavor to correct any unhealthy state of the womb by fur- 
thering involution, later by proper treatment and by obtaining 
as long a period of rest for the organ as possible ; during preg- 
nancy, by preserving a high standard of health and removing 
causes which tend to lower nerve force; during labor, by hus- 
banding the strength both of the uterus and patient, by securing 
for both proper intervals of rest, by giving support in the form 
of strong soups, or meat if it can be taken, and by rendering 
mechanical assistance as soon as it can fairly be done, if labor 
threaten to become lingering, without waiting for actual inertia 
to supervene ; after delivery, by insuring efficient contraction by 
gentle means, by obtaining complete rest, local and general, and 
by inducing sleep as soon after as may seem fit. Chloral is far 
better than opium for this purpose, and among other reasons not 
the least 'is, that it does not prevent (as opium) uterine contrac- 
tion. It is also advisable not to apply the child too early to the 
breast, for if it sucks vigorously before milk is secreted, great 
pain often results, or an irritable condition is induced, in which 
the uterus and its nerves are not slow to participate. If the 
interval between delivery and the first flow of colostrum be em- 
ployed in obtaining quiet and sleep for the mother, and in giving 
as much nourishment in anj form as she can take, avoiding ex- 
cess of fluids, when the breasts fill and the child begins to draw 
the nipple, the uterine contractions which result will be in most 



AFTEK-PAIJS'S. 395 

cases unperceived, or, at most, the pain will never be so great as 
to disturb sleep. 

3. Rheumatic After-pains will respond best to anodynes exter- 
nally, with salicin or salicylate of soda and quinine internally, 
and the avoidance of the sources of irritation before mentioned. 

4. After-pains connected with Utero- Ovarian Nerves. This 
pain is a genuine neuralgia of the pelvic nerves, and any treat- 
ment, be its object the prevention or the cure of the pain, must, 
if it is to be successful, be based upon this understanding. The 
patients who are most prone to suffer from these pains belong 
especially to that class whose physical defect lies in their nervous 
system. They are rarely quite free from all aches and pains, 
but suffer chiefly from spine-ache with tenderness on pressure 
over the vertebrae ; from pain in the ovarian regions, especially 
the left; from intercostal neuralgia, mammary pains, migraine, 
and such like. In them a sensation which in another escapes 
notice is pain, ordinary pain is agony. Many doubtless willfully 
or unconsciously exaggerate, but. as many more bear abundant 
witness to the reality of their suffering in their general condition. 
The pains which they suffer are identical with those they have 
felt before at the menstrual period, or when their tide of health 
was rather lower than usual, and depends upon the same cause, 
pelvic excitement. They undoubtedly require identical treat- 
ment. A girl who has thus suffered before marriage is, save in 
some exceptional cases where marriage itself or diversions attend- 
ing it remove the depraved nervous condition, almost sure to 
suffer during pregnancy and af er-delivery, even though it be 
her first conception. Careful treatment during pregnancy is in 
all these cases well repaid. Our one aim must be to combat the 
constitutional defect by all the adjuncts of change of scene, exer- 
cise in the open air, and any means of raising the tone both of 
nerve and muscle. " Early to bed " is indispensable. Every- 
thing is to be avoided which tends to excite or depress the nervous 
system. Local pain and discomfort is to be avoided by the use 
of well-fitting belts to prevent dragging on the broad ligaments, 
and by passing part of every day recumbent upon a couch or 



396 COMPLICATIONS OF PARTURITION. 

bed raised at the foot. Irritability or uncertainty of temper, 
which is very commonly present, responds best to the use of the 
bromides. These, also, as well as hot applications to the abdo- 
men, best control too vigorous foetal movements. If pain be 
present, and a tonic seems necessary, zinc, valerian, bromides, 
phosphorus, quinine, or bark, with hydrobromic acid, conia, etc., 
and other sedatives, will be most useful, and in some cases iron, 
especially if the periods have been pale before marriage. The 
four great requirements are food, sleep, local rest, and absence of 
all disturbing influences. Treatment during labor and after must 
be on almost the same lines as for spasmodic pains ; quinine and 
sedative liniments are especially useful. Where, from the nature 
of the labor, much general stiffness is to be expected, good results 
are obtained from the use of tinct. arnicas, Tf^x., after delivery. 
It is surprising in how many of these cases a small faecal accu- 
mulation helps to keep up the pain, a contingency which should 
always be kept in mind. 

5. Disturbances of the Cerebrospinal System do not admit of 
any special treatment, be they motor or sensory. Quinine and 
morphia are most frequently useful. 

6. Pains in the Rectum or Bladder only demand notice to im- 
press upon us the necessity of ascertaining that pain is not de- 
pendent upon their imperfect evacuation. Intestinal flatulent 
distention, however, requires closer attention. There can be no 
doubt that, especially in persons with pendulous abdomens, the 
ordinary diet of the lying-in room, consisting, as it too often does 
during the earlier days, of slops in inordinate quantities, is 
chiefly to blame for this. Some blame must also be given to 
want of support to the abdominal walls before, and inefficient 
bandaging after labor. Patients who are disposed to suffer thus 
should have a generous diet, with very little more liquid than 
they usually take, and should be securely bandaged so as to exert 
firm and evenly-distributed pressure upon the intestines. If 
flatus accumulate, anti-spasmodics may be given by the mouth, or 
an enema of turpentine and asafoetida, whilst constipation, if 
present, must be corrected. If the pain be excessive, morphia 



AFTER-PAINS. 397 

hypoderinically will best relieve it whilst curative means are in 
course of trial. Poultices with mustard or fomentations with 
turpentine, followed by laudanum on cotton- wool, often give 
great relief. 

ALFRED MEADOWS, M. D., LONDON. 

This author believes after-pains to be healthful in a certain 
sense ; but if excessive, he would give henbane and camphor, 
lettuce and chlorodyne, morphia, which is better than opium, and 
the liquid extract of the British Pharmacopoeia is the best of the 
opiates. The regular application of the child to the breast suf- 
fices to expel clots from the uterus. 

PROF. W. S. PLAYFAIR, M. D., LONDON, 

Advises an opiate, or if the lochia be scanty, a linseed-meal poul- 
tice sprinkled with laudanum, or the chloroform and belladonna 
liniment. Quinine in ten-grain doses is excellent, especially 
when the pains are neuralgic in character. 



PROF. 



Counsels the removal of any coagula that may be in the uterus. 
When the pains are neuralgic, an opiate, and a warm linseed- 
meal poultice, with laudanum sprinkled on it, applied to the 
abdomen, afford great relief. An anodyne embrocation applied 
to the breasts is of service. 



M. D. 



Has found (Medical Press and Circular, February 20th, 1878,) 
small doses of opium, frequently repeated, combined with an 
alkali or acid, as indicated, to answer an excellent purpose. It 
is much safer than giving a single large dose, which has a ten- 
dency to suddenly paralyze nervous action, and subsequently 



398 COMPLICATIONS OF PARTURITION.- 

lead to passive enlargement and congestion of the uterus. This 
objection derives additional force from the occasional presence 
(often unsuspected by the young accoucheur) of albumen in the 
urine, and the consequent danger of ursemic convulsions ; when, 
if a large dose of the narcotic be blindly administered, fatal 
effects will almost inevitably follow. Here there is no remedy 
to compare in safety and value with the old-fashioned tincture of 
iron, which may be given, properly diluted, in large doses and 
ad libitum. When pains, unattended by uterine action, follow 
labor, ergot may be advantageously prescribed. But to exhibit 
it in cases where the viscus is already, so to speak, madly in 
action, would be simply applying spurs to the willing horse. 

BESUME OF EEMEDIES. 

Actcea Alba. The white cohosh in tincture or infusion is alleged 
by the eclectic practitioners to be a specific in after- 
pains. 

Camphora, in the form of camphor-water, or pills, gr. ij., of the 
powder, may be used with advantage. 

Chloral, in moderate doses, will usually be found efficient. 

Uyoscyamus is well spoken of by Dr. Meadows. 

Lupulina, from its specific sedative effect on the generative sys- 
tem, has been suggested. 

Opium and its alkaloids are extensively given, but may profit- 
ably be supplanted by other anodynes. 

Potassli Bromidum is a safe, and usually an efficient, sedative. 

Qainio3 Sulphas, in doses of gr. x., repeated if required, has a 
great deal of testimony in its favor. 

Hot- WoUr Injections. Dr. Albert H. Smith, of Philadelphia, 
has found that hot-water injections, 110° to 120° Fah., 
will always relieve, and often arrest, the most severe 
forms of after-pains. (Med. Times, August, 1879.) 



PUERPERAL HEMORRHAGE. 399 



PUERPERAL HEMORRHAGE. 

Hemorrhage may occur either before labor or after it. Ante- 
partum hemorrhage may be due to the existence of placenta 
prsevia, which generally is manifested by the bleeding occurring 
about the seventh month ; or to the accidental detachment of the 
placenta, or the rupture of a large vessel of the mouth or neck 
of the uterus, or in the vagina. This latter may be expected 
where the presence, of varicose veins is observed about the abdo- 
men, thighs, etc. We have reason to believe that the same con- 
dition may exist within the labia and vagina. When hemor- 
rhage occurs, until the os is sufficiently dilated to permit of 
delivery and a speedy termination of the labor, plugging the 
vagina is the only resource. This may be accomplished by the 
use of cotton, wool, etc., saturated in a styptic glycerine, or by 
the colpeurynter, which fully closes every avenue for the escape 
of the blood, and acts efficiently as a dilator of the os. This 
should never be filled with air, for should its walls give way 
above, the air would be forcibly driven into the uterine veins, 
and death would be inevitable. 

DE. S. S. MOSES, OF MISSOURI. 

Some suggestions, the result of thirty years' practice, are made 
by this practitioner in the St. Louis Courier of Medicine, March, 
1880. 

Preventive Treatment If the patient is of full habit, plethoric, 
with strong pulse, occasional headache, the judicious physican 
will endeavor to relieve this condition by diet, saline purgatives, 
and, if necessary, venesection. 

If, on the contrary, the patient is of a relaxed leuco-phlegmatic 
temperament, by proper exercise, tonics, the best of all, good 
beef-essence, and chalybeates, endeavor as far as possible, to in- 
vigorate and improve the general health. 



400 COMPLICATIONS OF PARTURITION. 

At the time of labor we should : 

1. Rupture the membranes early. 

2. Administer a full dose of ergot just before the birth of the 
child. 

3. Avoid emptying the uterus too suddenly, and firmly com- 
press the fundus with the hand. 

In the general treatment of the bleeding, Dr. M. does not 
offer any novel resources. He states that he has used with ad- 
vantage the expedient of bandaging the extremities, applying to 
them a roller bandage to keep as large a supply of blood in the 
trunk as possible. 

DR. ISAAC E. TAYLOR, OF NEW YORK. 

As means of arresting the blood and exciting the muscular 
and nervous forces of the uterus to proper contractions this 
author has suggested (Independent Practitioner, Feb., 1880,) 
flagellation as presented in the following propositions : 

First, Flagellation or spanking the child's back moderately, 
every now and then, after the delivery of the shoulders, per- 
mitting the breech and the extremities of the child to remain in 
the vagina, and the feet thus placed in apposition with or in the 
cervix uteri, remaining for fifteen or twenty minutes or more 
without being withdrawn. Pressure over the uterus by the 
hand is to be avoided till the delivery of the child, which should 
be slow and gradual, as it might effect the delivery of the child 
before we have gained our object, and at the same time the 
spanking should be quick but gentle, and not too harsh, and 
continued until the delivery of the child is completed. 

Second. After the delivery of the placenta, should hemorrhage 
occur, expose the abdomen, and flagellate it with a towel doubled 
up, the ends held in the hand, saturated or not with ice-water. 
Several rapid and powerful strokes should be made, when the 
unrecognized uterus will be almost immediately felt contracting 
or contracted, no matter how profuse or rapid the flow may be. 

Should uterine contraction ensue and relaxation take place, a 



PUERPERAL HEMORRHAGE. 401 

milder application of the same means may be resorted to, till the 
contraction is deemed secure, and other measures adopted, if 
necessary. 

There can be no procrastination or temporizing action in these 
sudden and violent cases. The appearance of the method to 
those present, or to the patient herself if conscious, with the 
suddenness and rapidity of its appplication, may seem harsh, 
abrupt and unnecessary. We have, however, nothing to do with 
appearances or feelings in such critical emergencies. We are 
imperatively reminded that life or death is swaying in the bal- 
ance. Duty commands decided and prompt action. By this 
procedure Dr. T. has in some instances had the gratification of 
feeling the apparently lifeless organ fold itself up under the 
touch, the uterus contracting or contracted, and the patient's life 
safe certainly for the time being. In the course of thirty-five 
years, practice he has had to introduce the hand into the uterus 
to deliver the placenta but three times. This is an enormous 
advantage of this mode of treatment, when it is considered how 
frequently the hand or finger of the accoucheur conveys the 
septic poison into the blood. 

DR. GEO. J. ENGELMAN, OF ST. LOUIS, 

Gives, from his own experience (St. Louis Med. and Surg. Jour., 
July, 1880,) the following as the most rational and successful 
rules for the treatment of post-partum hemorrhage : 

A. — PREVENTIVE TREATMENT AFTER INDUCTION OF LABOR. 

1 . Careful attention to every detail, and strict observance of 
obstetric rules in every case of labor. 

* 2. The administration of a full dose of ergot as the head enters 
the vaginal orifice. 

3. Should hemorrhage threaten, follow the uterine fundus with 
the firmly superimposed hand. 

4. Express the placenta by Crede's method, and retain a firm 
grasp upon the fundus. 

26 



402 COMPLICATIONS OF PARTURITION. 

B. — TREATMENT OF AN EXISTING HEMORRHAGE. 

1. External manipulation, pressure, and friction with the cold 
hand, or with ice. 

2. Ergot — best subcutaneously, one or two large doses, whilst 
other manipulations are in progress. 

3. Introduction of the hand into the vagina, and if no con- 
tractions follow, into the uterus ; removal of the clots and irri- 
tation of the surface, in order to stimulate contractions. 

4. The subcutaneous administration of ether. 

4a. Ice or vinegar, if at hand, may now be tried in the uterine 
cavity, but if they fail, must not be persisted in. 

5. The hot- water douche, which, if it is not followed by the 
desired contraction, will at least stimulate the patient, and cleanse 
the cavity, so that the final, safest and most reliable remedy may 
be resorted to. 

6. The iron swab. This may be used at once, if the intro- 
duction of the hand and the subcutaneous injection of ether 
fail, or after the trial of the hot-water douche ; but in desperate 
cases must be resorted to at once, without losing time with other 
less reliable methods. 

PROF. W. S. PLAYFAIR, M. D., LONDON, 

Gives the treatment by puncture of the membranes as the most 
efficacious; plugging the vagina, or, better, the cervix itself; 
turning, of course, when dilatation admits of it, as after the pre- 
vious plan ; separation of the placenta, especially when the child 
is dead, when it is not yet viable, when the hemorrhage is great 
and dilatation is not sufficient for turning, when the pelvic pas- 
sages are too small for safe and easy turning, when the mother 
is too exhausted to bear turning, when the evacuation of the 
waters fails, or when the uterus it too firmly contracted for 
turning. 

This operation is performed by passing one or two fingers as 
far through the os as they will go ; feeling the placenta, pass the 



PUERPERAL HEMORRHAGE. 403 

finger between it and the uterus, sweep it around so as to sepa- 
rate the placenta as far as can be reached ; if the membranes can 
be reached and have not been already opened, tear them. Gen- 
erally the hemorrhage soon ceases. 

He recapitulates : Before viability, temporize, by absolute rest 
in bed, cold, astringent pessaries, etc. After the seventh month, 
terminate the pregnancy. In all cases, rupture the membranes. 
If the bleeding ceases, leave the case to nature; if not, turn, if it 
can be done, or plug carefully, and endeavor, by compression 
and ergot, to bring on labor. Do not leave the plug in but a 
few hours. If necessary, use Barnes' bag to dilate; this also 
acts as a plug. Separate the placenta from its attachment to the 
cervix. 

Of course, all these methods would apply for any form of ante- 
partum haemorrhage. The great haemostatic is uterine contrac- 
tion. 

PROF. F. WINCKEL, M. D., DRESDEN, GERMANY. 

When from absence of contractions, give ergot three grammes, 
every fifteen minutes ; cold injections into the vagina ; compres- 
sion with the hand is preferable to all other measures. If pros- 
tration is the cause, claret, one to two teaspoonfuls every five 
to ten minutes. If all else fails, styptics must be applied to the 
inner surface of the uterus, as ice, in small pieces the size of a 
walnut; or introduce liq. ferri sesqui-chlorid. by means of a 
cylindrical wad of cotton-wool soaked in it ; or inject equal parts 
of iron and water with Braun's syringe. 

When stricture and irregular contraction are present, and the 
patient complains of severe after-pains, anti-spasmodics are best, 
as pulv. ipec. comp., laudanum, an emetic, or a sinapism over 
the sacrum after the clots have been removed from the uterus. 
Enemata with twenty drops of laudanum, an emulsion of bitter 
almonds, with twenty drops of extract of hyoscyamus, are of 
great service. 



404 COMPLICATIONS OF PARTURITION. 

"When the uterus is firmly contracted, and the genitals and 
vagina are not the seat of hemorrhage, it must arise from the 
cervix, and local styptics are required, as cold injections, made 
of cotton-wool soaked in solution of chloride of iron, passed 
into the cervix, and plugging the vagina with balls of cotton- 
wool rather than the colpeurynter. Manget squeezed the juice 
out of half a lemon into the cervix with complete success. 

A. D. L. NAPIER, M. D., LONDON, 

(Obst. Jour. Great Britain and Ireland, Feb., 1877,) observes that 
we should have no fear of using iron injections, as the os is patu- 
lous, and the return of the fluid is certain. Absorption is not active, 
hence we need not fear pyaemia. Brandy, beef-tea, and ergot are 
foremost as internal treatments. Ergot is greatly increased in its 
specific action by the addition of strychnia. 

H. OTIS HYATT, M. D., KINGSTON, N. C, 

(Obstet. Jour. Great Britain and Ireland, Sept., 1877,) proposes the 
use of the condom, or, better, the toy balloon tied over the end 
of a Davidson syringe nozzle, and passed within the flaccid 
womb, and then distended by warm or cold water, thus pressing 
directly upon the mouths of the bleeding vessels. He has suc- 
cessfully employed it in a number of cases. He regards it as 
effectual in one or two minutes ; and harmless, as, if it should 
burst, it would only wash out the womb. 



In secondary post-partum hemorrhage, (Archives de Tocologie, 
ISTov., 1877,) has used the hot bath with great success. One had 
hemorrhage eighteen days after delivery. The uterus could be 
felt two fingers 7 breadths above the pubes. Spite of injections of 
iron and the use of ergot, the loss continued obstinately for ten 
days. After the first hot bath, the loss was much diminished ; 



PUERPERAL HEMORRHAGE. 405 

after the second, it was suspended. It recurred in thirty-six 
hours, but a third bath arrested it, and involution was rapidly 
completed. A similar case set in twenty-seven days after delivery. 
It was continuous and profuse. A hot bath of twenty minutes' 
duration entirely stopped the hemorrhage. He attributes the 
benefit to the relief of uterine congestion, consequent upon the 
dilatation of cutaneous capillaries, the resulting determination of 
blood to the surface, and diminished vascularity of deep-seated 
organs. The baths are of a temperature of 34° Cent., and the 
immersion from twenty to thirty minutes. 

DR. KOEHLER, OF GERMANY. 

This writer (Al\ Med. Central-Zeitung, No. 1, 1879,) states 
that he has, for the last seven years, in cases of uterine hemor- 
rhage, applied warm fomentations to the head, to prevent anaemia 
of the brain, and also to the heart. Hot sand-bags are also very 
efficient, and the patients often will bear sand which is so hot 
that it can scarcely be touched with the hand. As soon as the 
fomentation or bag has been applied, consciousness is restored ; 
the pulse grows stronger; the patient herself states that she feels 
better; that the ringing in the ears has ceased, and that she likes 
the appliance. As soon as it becomes cooler, she wishes it to 
be renewed. Dr. Koehler has, he says, saved patients even 
in the most dangerous cases of hemorrhage, by this proceeding, 
by which the physician never loses time, as the fomentations may 
be watched and renewed by any one. 

JAMES BRISBANE, M. P., OF LONDON, 

Uses perchloride of iron by the u ready method ; " it acts like 
a charm. Nothing more is required than to carry a two-ounce 
bottle of ordinary tincture of the chloride of iron. A piece of 
sponge is compressed in the palm of the hand, and the iron 
poured on it, and thus conveyed up to the bleeding surface of the 
uterus, there pressed and left. The blood coagulates, the womb 
contracts, and the danger is over. At the next visit, the sponge 
is found in the vagina, and no bad results follow. It is better 



406 COMPLICATIONS OF PARTUKITION. 

than injections, no time is lost, and the objections of thrombosis, 
injecting air, etc., are obviated. 

PROF. KARL SCHROEDER, BERLIN. 

This author counsels the tampon or colpeurynter, etc. ; as soon 
cs the dilatation will allow it, a finger should be passed to one 
side when the placenta is lateral, and an effort made to turn by 
one foot. When the placenta is central, one cotyledon is to be 
separated from the side of the os, and then the foot sought for. 
One foot is to be brought down, and so on until the delivery is 
complete. It is, however, advisable to continue with the tam- 
pon until the head is firmly pressed against the bleeding surface, 
or until dilatation will allow of turning. It is always best for 
mother and child to turn as soon as practicable, and only to omit 
doing so when the head stops the bleeding. The forceps may be 
used if necessary. If the child is dead, the placenta may be sep- 
arated entirely, and delivered before the child. 

Hemorrhage may also arise from the vessels of the cord, and 
the child is in great danger. Here the rupture of the membranes 
should be delayed as long as possible, and the rubber-bag used 
until dilatation will allow of immediate extraction. 



Accidental hemorrhage is known by the blood being almost 
entirely liquor sanguinis. In placenta prsevia, the vagina is 
filled with coagula. The treatment will be recumbent position, 
cool drinks, astringents, as the acetate of lead, two grains given 
in one-half a drachm of dilute acetic acid, to prevent its decom- 
position in the stomach, every four or six hours ; or gallic acid ; 
or sulphuric acid, as in the infus. rosse cornp., or both combined, 
which is far more powerful than singly ; opiates in large doses. 
If these fail, plug the vagina. Avoid this if possible, when the 
time is not full, as it is liable to bring on labor. The plug must 
be firm, and the vagina completely filled. Its effects will be en- 



PUERPERAL HEMORRHAGE. 407 

hance'l if, at the same time, a firm bandage is placed over the 
abdomen. The vagina must be full, but not distended. 

When the discharge is very great, with pain and pregnancy at 
full time, expedite delivery. 

In placenta prsevia, act according to the necessities of the case ; 
plug and wait for dilatation, then turn and deliver. If there is 
not dilatation, aud the loss is great, puncture the membranes, 
and secure dilatation with the rubber dilators, and deliver 
speedily. The separation of the placenta seems to be most safe. 

When due to retention of the placenta, introduce the hand 
and peel it off with the utmost carefulness. In doing this, keep 
the other hand on the fundus uteri, so as to steady the womb. 
Next guard against the evil effects of decomposition by syring- 
ing with antiseptics. When due to atony of the uterus, use 
ergot, cold, pressure and galvanism. These failing, introduce 
the hand to excite the womb to contract. 

When the womb relaxes after once contracting, support the 
patient with brandy ; grasp the womb firmly, and by pressure 
cause it to expel its contents, or turn them out with the other 
hand. Irritate it by manipulation within and without. Ice may 
be introduced within the organ, or a cold douche thrown on the 
abdomen. 

Electricity rarely fails to induce permanent contraction. Place 
one pole over the fundus and the other on the periuseum. 

All failing, inject solution of perchloride of iron into the uterus, 
first clearing out all coagula. Remember the danger of this 
injection, and only use it as a last resort. 

PROF. WM. LEISHMAN, M. D., GLASGOW, 

Epitomizes thus : The evacuation of the waters is best in partial 
placenta prsevia, and where the membranes can be reached, and 
where the foetus is immature. 

Ergot and oxytocics may be given, but it must be remembered 
that these and the above render turning; more difficult. 

Plugging is called for, and may be applied in the vagina or 



408 COMPLICATIONS OF PARTURITION. 

in the os uteri; it is a temporary expedient, and in turning is 
essential as a preliminary. 

Extraction of the placenta is not to be done unless the circum- 
stances are very exceptional, as when turning is impossible, and 
separation has failed. 

Separation of the placenta is more justifiable, but the opera- 
tion of turning is that in which the majority place the greatest- 
confidence. 

PROF. FORDYCE BARKER, M. P., NEW YORK. 

This author recommends the production of contraction by 
pressure by the hand ; the removal of any blood clots that may 
remain in the uterus ; ice in the vagina ; injection into the uterus 
of half an ounce of the solution of the subsulphate of iron, 
diluted with an equal measure of water ; and internally adminis- 
ter thirty drops of the fluid extract of ergot with twenty drops 
of the tincture of mix vomica every half hour, until well assured 
that the uterus is well contracted. If the patient has suffered a 
severe shock from loss of blood, twenty drops of laudanum and 
alcoholic stimulants should be given, and repeated at short inter- 
vals until reaction is restored, and then give the ergot and nux 
vomica. 

If there be a portion of the placenta retained, the ergot and 
nux vomica should be administered as a precautionary measure. 

If the hemorrhage results from a uterine polypus, Dr. Bar- 
ker recommends its removal with the vulsella forceps. If from 
laceration of the vagina or vulva, involving varicose veins or 
arteries, he recommends ligation or such local measures as are 
demanded in hemorrhages. 

PROF. T. G. THOMAS, M. D., NEW YORK, 

Urges (American Practitioner, May, 1877,) the induction of pre- 
mature labor in placenta prsevia. It is the only method by which 
the danger can be avoided. It is a rational and perfectly war- 



PUERPERAL HEMORRHAGE. 409 

rantable means, and has no danger to be compared with that of 
non-interference. It removes the hazards incident to delay, and 
relieves the great anxiety of patients, friends and physicians. 



Gives the resources thus (Am. Jour. Obstet., No. 36, p. 576) : 
They are enumerated in the order they are to be employed — (1) 
Friction, kneading and compression of the uterus. (2) Hypo- 
dermic injection of ergot above the symphysis pubis. (3) Injec- 
tion of hot water at a temperature of at least 100° F. into the 
uterine cavity. (4) The injection of Churchill's or U. S. tinc- 
ture of iodine into the uterus. 

Ergot, thus hypodermically used, he says, unfolds its peculiar 
power over the muscular tissue with a degree of promptness and 
certainty of which those who know of the action of the drug only 
through the other modes of administration can have no idea. 

He refers to intra-uterine injections of ergot in the following 
manner : Remove coagula ; then, with a Davidson syringe, wash 
out all blood with cold water, and quickly inject into the cavity 
f. I ss. Squibb's fluid extract of ergot, with water f. §iv. The 
effect has invariably been to bring on promptly strong, perma- 
nent tonic contraction of the muscular fibres of the uterus. 

Dr. Strudwich has tried it in six cases of hemorrhage, and 
says it surpasses Mo'nsel's styptic. 

He has never been disappointed in ergot thus applied, and 
confidently recommends its use to those who have never tried it. 
Its superiority over the iron treatment must be obvious to any 
intelligent practitioner, since the latter application is often fol- 
lowed by serious consequences, and is never used without grave 
apprehensions of serious results, whereas the ergot is perfectly 
harmless and unirritating. 

Some critic may say the result obtained should be ascribed to 
removal of coagula and cold injections, etc. ; but such is not the 
case, since after trying all those measures repeatedly — with ergot 
by mouth and rectum — each time only bringing on slight trans- 



410 COMPLICATIONS OF PARTURITION. 

ient contraction, until ergot was tried, with the unfailing success 
which always attends its use when thus applied. 

PROF. W. S. PLAYFAIR, M. D., LOSDOX, 

Urges preventive treatment in all cases. The hand should be 
kept upon the womb until the placenta is expelled, and con- 
tinuous contraction kept up for at least half an hour after deliv- 
ery, by grasping the contracted womb with the palm of the 
hand and preventing its relaxation. It is also good practice to 
give a full dose of ergot after the placenta has been delivered. 
AVhen the previous history causes an expectation of hemorrhage, 
the ergot should be given, and preferably hypodermically, about 
ten or twenty minutes before the labor is expected to be con- 
cluded. Then any means should be taken to insure contraction 
of the organ, and it is advisable to rupture the membranes early, 
as soon as the os is dilated or dilatable, to insure stronger uterine 
action. Care should be had in all cases where the pulse is high 
some ten or fifteen minutes after the birth of the child, as 
hemorrhage often follows. Hence, never leave a patient until 
the pulse falls to the normal. After speaking of pressure, he 
alludes to another plan : pass the fingers of the right hand high 
up in the posterior cul-de-sac of the vagina, so as to reach the 
posterior surface of the uterus, while counter-pressure is exer- 
cised by the left hand through the abdomen. The anterior and 
posterior walls are thus closely pressed together. 

Brandy must not be relied upon. In bad cases it merely fills 
the stomach, and may be thrown up unaltered. It may bring 
on intoxication, which is mistaken for coma of syncope, etc. 

A drachm of ether may be injected hypodermically in great 
exhaustion. Give fresh air, keep the head low down, so that 
syncope cannot occur. Empty the uterus of clots or other 
foreign bodies. 

Intra-uterine injections of warm water, 110° to 120°, are 
highly recommended. This succeeds after all the usual remedies 
fail, especially where the uterus contracts and relaxes. 



PUERPERAL HEMORRHAGE. 411 

A distended bladder will often prevent contraction. Evacuate 
it with the catheter. 

Never plug the vagina. 

Compression of the abdominal aorta is a temporary expedient, 
and supplements other means, as also when there is great exhaus- 
tion, the firm bandaging of the extremities with the elastic band- 
age, to retain the blood in the trunk, and lessen the likelihood to 
syncope. 

In the last extremity, inject the strong liquor of chloride of 
iron, diluted with six times its bulk of water, being very careful 
to exclude the air from the syringe. 

The secondary treatment will be opium as a restorative, thirty 
to forty drops of Battley's solution by the mouth or in enema, 
quiet, beef-essence, milk, eggs, etc., in small quantities given 
frequently. Stimulants as demanded. 

PROF. R. A. F. PENROSE, M. D., PHILADELPHIA, 

Saturates a cloth with common vinegar, and passes it into the 
uterine cavity, and squeezes it. In a paper read before the 
American Gynecological Society, he claims that this procedure 
rarely fails to stop the flow immediately. It can be easily ob- 
tained. It can be easily and instantly applied without apparatus. 
It has never failed in his practice. It is sufficiently irritating to 
excite the most sluggish uterus to contraction, and yet not so 
irritating as to be subsequently injurious. It is an admirable 
antiseptic. It acts upon tthe lining membrane of the uterus 
as an astringent. 

H. P. C. WILSON, M. D., BALTIMORE, 

Urges the introduction of the hand within the uterus, and raking 
the surface which has been occupied by the placenta with the 
finger-nails. He says that in one case no further hemorrhage 
occurred, though the uterus did not contract, and its mouth 
remained open for nearly an hour after this operation. 



412 COMPLICATIONS OF PARTURITION. 

LOMBE ATHILL, M. D., OF DUBLIN. 

This author is convinced that there are cases where a powerful 
local haemostatic in the uterus is absolutely essential to save life. 
He states his conclusions formally : 

1. That cases of post-partum hemorrhage occur in which the 
injection of the perchloride of iron, or some similar styptic, is 
alone capable of arresting the hemorrhage. 

2. That the injection of such styptic does not necessarily 
increase the tendency which exists in such cases to the occurrence 
of pyaemia, septicaemia, or peritonitis. 

3. That this treatment is specially applicable to anaemic pa- 
tients. 

4. That while it should never be had recourse to unnecessa- 
rily, it should not, on the other hand, be delayed too long. 

In using the solution of the perchloride of iron, he carries out 
in the main the directions given by Dr. Barnes. He has not, 
however, in any case, injected more than six or eight ounces, 
sometimes as little as four ounces of the fluid. He also uses it 
somewhat stronger than Dr. B. does — namely, in the proportion 
of one part of the strong liquor, B. P., to two of water. The 
important point in using it is to take care that the end of the 
tube is passed up to the fundus of the uterus, and that the fluid 
be injected slowly. 



In using the hot water in post-partum hemorrhage, this prac- 
titioner [Canada Lancet, Nov., 1879,) dissolves in it one ounce of 
alum to the pint. He has found this attended with less disad- 
vantages than the tincture of the chloride of iron. In a com- 
parison of the two, he states the following conclusions : 

1. That we possess two powerful topical remedies for post- 
partum hemorrhage. 

2. That the iron is the more powerful to control hemorrhage, 
but by far the more dangerous one. 



PUERPERAL HEMORRHAGE. 413 

3. That hot water is nearly equal in haemostatic power, and 
without danger. 

4. That we are rarely justified in using the iron before the hot 
water has been tried. 

5. When the hot water fails, it is the duty of the accoucheur 
to use the iron. 

6. The hot water has these advantages over the iron : it can 
always be procured ; it washes away all clots, leaves the uterus 
clean, and, therefore, no danger from thrombus or septicaemia. 

7. Alum is a valuable addition to the hot water, securing two 
forces, viz., the contraction of the uterus and the coagulation of 
the blood. 

8. That we have not yet reached perfection in the treatment 
of the hemorrhage, and that abundant ground is open for obser- 
vation and research. 

In a discussion of this measure, at one of the London medi- 
cal societies recently, Dr. John Walters stated four conditions 
essential to success : 

1. The uterus must be emptied completely. 

2. The temperature of the water must be from 100° to 110°. 

3. The tube must be passed to the fundus. 

4. A considerable quantity of water must be used. 

The advantages of warm water are that it is cleanly, always at 
hand, antiseptic, and perfectly safe. He drew three conclusions : 

1. Severe hemorrhages are controlled by warm water. 

2. Cold or ice, in conjunction, is useful. 

3. In some cases, perchloride of iron must still be used. 

KESUME OF EEMEDIES. 

Acetum. Vinegar has a long-standing reputation in post-partum 
hemorrhage. Dr. Davis (Obstetric Medicine, 1836,) 
recommended the intra-uterine injection of one part of 
vinegar to two of water. It has recently been highly 
praised by Dr. Penrose, of Philadelphia. (See p. 
411.) 

Cannabis Indica was much esteemed by Dr. A. Christison, but 
most later observers have failed to verify his state- 



414 COMPLICATIONS OF PARTURITION. 

ments. Dr. Wm. Donovan, however {Edinburgh 
Med. Jour. , June, 1875,) says in doses of gtt. xx. p. r. 
n., he never knew it to fail. 

Capsicum. A teaspoonful of tincture of capsicum will often 
prove the best of stimulants in atony. 

Chloralum, as at once a styptic and antiseptic, has been preferred 
for intra-uterine injections by some writers. 

Ergota has been used in large doses by the mouth, in hypoder- 
mic injection, and locally as an intra-uterine applica- 
tion. Dr. Lombe Atthill says that it is a most un- 
certain agent, and while most useful if administered 
some time before the occurrence of the hemorrhage, is, 
in his opinion, seldom of much value if given after it 
has set in. Ergot takes at least twenty minutes to act, 
and besides is often in these cases vomited. Injected 
hypodermically, it is capable of doing much good ; 
but its irritating properties when thus used, render 
this method of employing it not altogether unobjec- 
tionable. 

Erigeron Canadense, the " squaw- weed," has a popular reputa- 
tion as a haemostatic in uterine hemorrhage. A tea- 
cupful of the infusion or five drops of the oil, may be 
given every half hour in light cases. 

Ether has been used in hypodermic injection and as spray to the 
hypogastric region. The former has been especially 
recommended by Prof. Von Hecker, of Munich, in 
conditions of collapse from hemorrhage. The chief 
point to be attended to in making the injection, is to 
pass the syringe well down in the subcutaneous cellular 
tissue ; otherwise troublesome abscesses may form at 
the seat of the injection. The quantity to be injected 
depends entirely on the pulse. Professor Vox Hecker 
frequently injects from two to four drachms at short 
intervals. The effect is very transient, so that the in- 
jection may have to be repeated. 

Ferri Chloridi Tindura, strongly eulogized by Barnes, Att- 
hile, Hicks, and others as an intra-uterine injection, 
has been severely condemned by Dr. Snow Beck as 
dangerous. In certain desperate cases it seems the only 
resource which is efficient. (See page 410.) The tinc- 
ture may be diluted, or used of full strength. The 
tube of the syringe should be carried to the fundus, 



PUERPERAL HEMORRHAGE. 415 

and the contents gently injected ; or a sponge or wad 
of cotton may be steeped in the solution and carried to 
the fundus. It should also be freely given internally 
in those cases where sluggish bleeding takes place for 
two weeks after delivery. 

Ferri Sulphas and MonseVs Solution have at times been used, and 
may have some advantages over the chloride. Dr. 
Wilson, of Baltimore, states that the sub-sulphate 
should be combined with glycerine, as the simple solu- 
tion acts as an irritant. Others use f. i ij. of Monsel's 
solution to water f. 1 vj., to wash out the uterus. It is 
sure to check the hemorrhage, but the sequels may not 
be agreeable. 

Iodinii Tinctura has been used, some employing several drachms 
of the pure tincture, others diluting it in the propor- 
tion of f. 3 j. to water f. f j. In a paper read before the 
Obstetrical Society of London, October, 1874, Dr. 
Trask recommends this article as an injection into the 
cavity of the uterus, in hemorrhage after delivery, as 
perfectly safe — at any rate, free from the evils incident to 
the employment of iron. It is an antiseptic, and is 
probably the surest of all means of counteracting a 
tendency to absorption of septic matter into the system 
after delivery. Dr. Forrest, (Med. Record, Septem- 
ber, 1880,) thus sums up its advantages: 1. Iodine 
controls the hemorrhage not by coagulating the blood 
in the uterus, but by exciting contraction. The blood 
is expelled in a liquid form, and instead of leaving the 
uterus filled with a mass of hard, sticky clots, ready to 
undergo decomposition, the uterus is emptied and dis- 
infected. 2. Iodine has never done any harm, even 
when injected in its full strength. In one case nearly 
six ounces were injected, four of these being undiluted. 
3. The iodine never fails to control the bleeding. 

Ipecacuanha. In some cases a full dose of this drug, bringing 
on rapid emesis, causes strong contraction after inertia, 
and promptly checks the hemorrhage. 

Nitrite of Amyl has been used by Dr. E. W. Kerr (Brit. Med. 
Jour., November, 1st, 1869,) with excellent effect. 
Five minims were administered through an inhaler. 

Plumbi Acetas. Dr. J. Workman, of Toronto, (Canada Lancet, 
January, 1878,) urges acetate of lead in large doses, 



416 COMPLICATIONS OF PARTURITION. 

from one-half a drachm to one drachm ; it will gener- 
ally be found that in these large doses it acts as a mod- 
erate purgative within twenty- four hours; and, if it be 
desirable that, in order to avoid transformation, it 
should be expelled from the bowels in this way, it may 
be better to err on the safer side, which certainly is not 
its exhibition in small doses. In one case he gave six 
drachms in twelve hours. He quotes Dr. Daniel 
Clark and others of eminence, who give it in even 
larger doses, and with like good result. 
Viscum Album, the mistletoe, has been introduced as an agent in 
post-partum hemorrhage by Dr. W. H. Long, U. S. 
M. H. S. (Louisville Med. Neivs, March, 1878.) But 
as it requires "from twenty-five to fifty minutes" to 
produce uterine contractions, its efficiency is slight. 



GENERAL MEASURES. 

Cold. This should never be neglected. Fanning the genitals, 
spinal ice-bags, injections of ice-water, a lump of ice in 
the uterus, ether or rhigolene spray to the hypogastric 
region, spine or thighs, are some of the methods in 
which it may be used. A tumblerful of ice-water fla- 
vored with brandy will sometimes act like magic, when 
given just after the second stage is completed. 

Compression of the Abdominal Aorta may be carried out in thin 
subjects with delicate abdominal parietes. 

Electricity and Galvanism have been found of decided advantage 
in some light cases, but cannot be depended on in 
severe ones. 

Heat is at times more energetic than cold.' Chapman's spinal 
hot- water bags have been spoken of for the purpose. 
Dr. Windebrand reported {Deutsche Med. Woch , 
June, 1876,) a desperate case where he threw into the 
uterus water at 120° F. by means of a uterine tube, 
which immediately caused a renewal of the pains, 
which, after an interval of five or ten minutes, and 
some eight or ten injections had been made in the 
meantime, ended in the expulsion of the whole of the 
contents of the uterus. Other cases have been reported 
by Atthtll, Mann, etc. Dr. Koehler (Gazeta 



PUERPERAL HEMORRHAGE. 417 

CIcarsJca, No. 8, 1878,) has obtained relief in the most 
desperate cases by applying very hot sand-bags to the 
head and cardiac regions. They are particularly use- 
ful to prevent collapse, and do not interfere with other 
means. 

Mammary excitation, by applying the child, the mouth of the 
nurse or a cupping-glass, to the mammae, will occasion- 
ally excite uterine contractions. 

Massage of the uterus by gentle and continued " hand-kneading " 
is a simple and valuable plan to awaken the muscular 
contractility. 

Position is always of great value. "It is most important," ob- 
serves Dr. J. H. Aveling (Influence of Posture on 
Women, 1879,) "that every woman suffering from 
uterine hemorrhage should be immediately placed in a 
recumbent position with the hips raised as far above 
the level of the shoulders as can conveniently be 
effected." 

Pressure. "The value of pressure on the fundus," says Dr. 
Atthill, " can hardly be overestimated. It should 
be combined with friction." Mr. David Christie 
(British MedicalJoumal, June, 1 878,) describes a method 
of arresting uterine hemorrhage by fluid pressure. He 
introduces an elastic bag into the uterus, connected 
with a tube seven feet and a half in length, the free 
end of which, after the bag is filled, is placed in water 
at the proper height. Mr. Christie reasoned that, as 
a tube placed in an artery has a column of water raised 
seven and a half feet by the heart's action, so his method 
would effectually arrest any hemorrhage that could 
occur, and allow the womb to contract and relax with- 
out the pressure of the water being interfered with. 

Sinapisms to the extremities are among the means currently used, 
but are not very efficient. These are aimed to bring 
the blood to the limbs. With a somewhat similar idea, 
Dr. Moller, of Vienna, has recommended (Wiener 
Med. Presse, No. 8, 1874,) applying the Esmarch band- 
age to the arms and legs. 

Transfusion has been growing in favor of recent years, in desperate 
cases of bleeding. The forms of transfusion most em- 
ployed and attended with the best results are : 
1. Transfusion with defibrinated blood. 
27 



418 COMPLICATIONS OF PAKTUKITION. 

2. Mediate transfusion with pure blood. 

3. Immediate transfusion from " vein to vein." 

4. Immediate transfusion from " artery to vein." 
The first and third methods are most generally 

adopted — the danger of clots is avoided. The second 
is generally abandoned, as leading to embolism, etc. 
Instead of blood, Dr. J. W. Howe (iV. Y. Med. Jour., 
1875,) recommended goat's milk; and Dr. T. G. 
Thomas and others have successfully employed cow's 
milk. The conclusions reached by Dr. Thomas are 
embraced in the following propositions : 

1. Injection of milk into the circulation, in place of 
blood, is a perfectly feasible, safe, and legitimate pro- 
cedure. 

2. In this procedure, none but healthy milk, drawn 
from the udder of the cow within a few minutes of its 
introduction into the vein, should be employed. 

3. A glass funnel, with a rubber tube and a suitable 
pipe attached, is much better and safer than a more 
elaborate apparatus. 

4. Intra-venous injection of milk is an infinitely 
easier operation to perform than transfusion of blood. 

5. Intra-venous injection of milk, like that of blood, 
is commonly followed by a chill and rapid rise of tem- 
perature ; but these symptoms soon subside, and are 
replaced by a great improvement in the general con- 
dition of the patient. 



PUERPERAL ECLAMPSIA. 419 



PUERPERAL ECLAMPSIA. 

For many valuable points on the prophylaxis of this compli- 
cation, see Albuminuria. 

DR. JOSEPH AMAM, MUNICH. 

Little can be accomplished in the way of prophylaxis. In 
treatment, the present position of science indicated that the 
remedies to be relied upon are exclusively the narcotics, chloro- 
form, opium, morphia and chloral. The rule is to give which- 
ever one is selected until it produces complete loss of control 
over the voluntary muscles. The first principle is to secure com- 
plete narcosis. To do this successive doses must be given until 
the amount required to bring about this condition has been 
taken. 

In urgent cases, chloroform effects this result most promptly. 
It should be pushed to complete ansesthesia. It is, however, not 
wholly without danger, especially when cardiac affections are 
present. Morphia acts more slowly, and is to be preferred when 
the case is less urgent. The proper dose is gr. J subcutaneously ; 
in 15 to 30 minutes it may be repeated if indicated. The effect 
lasts several hours or half a day. Opium is best given as an 
enema, gtt. xxv. of the tincture in f. 3 vij. of a vehicle, repeated 
until narcosis is produced. Chloral is also valuable. It is 
preferably given by the mouth, in doses of gr. xl.-L, in solution 
or as enema. 

In regard to venesection, it should be confined to special cases, 
namely, those in which positive symptoms of plethora are pres- 
ent, and then only when the convulsions occur before labor ; 
certainly during and after labor, blood enough has been lost, and 
there can be no sound reason offered for taking more. Experi- 
ence shows that the benefits from this measure have appeared in 
prseparturient cases. 

The wet pack, recommended by some writers, can do no harm 



420 COMPLICATIONS OF PARTURITION. 

if properly employed, and there are cases in which it will be 
useful. It requires, however, to be supplemented by the admin- 
istration of narcotics in the manner above described. 

PROF. KARL SCHROEDER. 

There are two methods of treatment, the abstraction of blood, 
or the use of narcotics. Venesection has often given favorable 
and exceedingly rapid results, but frequently the attacks have 
soon recurred, and then taken a more unfavorable course. A 
more rational treatment would be the paralysis of the activity of 
the voluntary muscles, and this can be done by narcotics ; thus 
the convulsions are certainly checked for hours, and the blood is 
not deteriorated. Scheinesson has shown by experiment that 
chloroform diminishes the blood pressure in the arterial system. 
Experience is decidedly in favor of this treatment; but to be 
effectual, the narcosis must be absolute, so that the voluntary 
muscles no longer contract. As long as an eyelid quivers, an- 
other dose is required. Chloroform will do this, but as it must 
be maintained, morphia is better ; or if haste is necessary, chlo- 
roform first, and replace it by subcutaneous injections of mor- 
phia. Chloral is also of great advantage, and may also be used 
subcutaneously ; or an enema of mucilage of starch, half cupful 
with 32 grains chloral in an ounce of decoction of althsea. 

Venesection may safely be omitted. Kb obstetric manipula- 
tion is required for the safety of the mother, but labor may be 
hastened to save the child. 



There are good grounds for believing that blood-letting is of 
only temporary use, and that it may even increase the convulsive 
tendency. In special cases, as where there is evidence of great 
cerebral congestion and vascular tension, as a livid face, a full- 
bounding pulse, and strong carotid pulsation, the patient a 
strong, healthy woman, it may be employed. Even here, a sin- 
gle bleeding is all that is ever likely to be of service. 



PUERPERAL ECLAMPSIA. 421 

As a temporary expedient, the carotids may be compressed. 

Purgatives to remove any irritant matter lodged in the intesti- 
nal tract, may act well ; as the comp. jalap powder in a full dose, 
or a drop of croton oil, or a quarter of a grain of elaterium may 
be placed on the back of the tongue. 

Chloroform may be used to control or ward off the paroxysm. 
It is advisable, however, to have a remedy more continuous in 
its action, and requiring less personal supervision. Chloral is 
decidedly this remedy, and, in combination with bromide of 
potassium, in the proportion of twenty grains of the former to 
half a drachm of the latter, repeated at intervals of from four 
to six hours. 

Dr. Harris, the American editor of Playfair, has used 
bromide of sodium and chloral with good effect at shorter inter- 
vals, and the chloral in doses of ten to fifteen graius. 

If the patient cannot swallow, it may be given by enema. 
The remarkable influence of bromide of potassium in control- 
ling the eclampsia of infants, seems to be an indication of its 
use here. 

Morphia may be given subcutaneously in the dose of one-third 
of a grain, repeated in a few hours so as to keep up its effect. 

Acetic and benzoic acid, as antidotes to ursemic poisoning, are 
too uncertain. 

During the paroxysm, prevent the patient from injuring her- 
self, especially biting her tongue, by placing something between 
her teeth. 

As to the delivery, adopt that course least likely to irritate. 
If the fits seem to be induced and kept up by the pressure of 
the foetus, and the head be within reach, apply the forceps, or 
even resort to craniotomy. Otherwise leave the case to nature. 

PROF. FORDYCE BARKER, M. D., NEW YORK. 

This physician places among the exciting causes of puerperal 
convulsions ; anaemia, albuminuria, uraemia, indigestion, constipa- 



422 COMPLICATIONS OF PAKTUKITION. 

tion, retention of urine, excessive distention of the uterus, reflex 
pains, or moral shocks. 

As a prophylactic, he removes as speedily and effectually as 
possible these exciting causes by appropriate treatment. If at 
the advent of labor, convulsions be threatened, he abstracts from 
the patient a moderate amount of blood, not enough to weaken 
her, but sufficient to restore the equilibrium of the circulation ; 
he does not permit the bladder to become distended. If the 
patient is irritable, restless, complains loudly of little annoyances, 
and is sleepless, he tranquilizes her by a moderate opiate. 

When the convulsion has occurred, he says, bleed at once, 
then give a brisk cathartic, as : 

313. R . Hydrarg. chloridi mitis, gr. x. 

Pulv. jalapse, gr. xx. M. 

Ft. pulv. No. j. Sig. — Take at once. 

But if she be comatose, he mixes a quarter of a grain of elate- 
riuni with a third of a teaspoonful of butter, and places it upon 
the back of the tongue. This is to be repeated every half hour 
until active catharsis. To arrest and prevent convulsions, ad- 
minister chloroform by inhalation. 

Having overcome the immediate danger from convulsions by 
the means stated, he administers a full dose of morphia hypoder- 
mically. 



In the Memoirs of the Belgian Academy of Medicine, 1876, sums 
up as follows the treatment of eclampsia in his memoir on the 
convulsions of parturient women, which was crowned by the 
Belgian Academy of Medicine : 

1. Mechanical eclampsia from the sixth to the ninth month : 
(a) Bleeding, if the caie be urgent, or if there be true or appa- 
rent plethora ; (6) drastics, in all cases, which may be more or 
less replaced by diaphoresis ; (c) chloroform when the fits are 
about to commence, and during the clonic convulsions; (d) 



PUERPERAL ECLAMPSIA. 423 

chloral in the intervals of the attacks, as an injection to benefi- 
cially fill the place of narcotics ; any antispasmodic, such as bro- 
mide of potassium, may be added to it (e) to finish the delivery, 
if possible, bring on labor, if the fits do not show signs of dis-. 
appearing; to bring on forced delivery in very serious cases. 

2. Keflex eclampsia before six months gestation, and after de- 
livery : (a) Bleeding is but very rarely indicated ; (6) purgatives 
are always somewhat useful ; (c) chloroform, chloral, etc., should 
be continued as in mechanical eclampsia, and antispasmodics 
should not be neglected. 

3. Toxic eclampsia : Fulfill the symptomatic indications ; gen- 
eral or local bleedings to combat congestion of the brain and 
spinal cord when it is very marked ; cold applications to the 
head, purgatives, diaphoretics, baths, revulsives, narcotics, anes- 
thetics, etc. 

M. DUNCAN, M. D., 

Comes to the conclusion (Practitioner, April, 1875,) thatBright's 
disease as a cause is over-estimated. A temporary appearance of 
albumen in the urine is no certain indication of Bright's disease. 
The treatment is to empty the uterus ; but, if labor is only com- 
mencing, it should only be done if the symptoms are desperate ; 
with severe and frequent fits, cyanosis and profound coma, move 
the bowels, draw oif the urine ; tide over the crisis with bleed- 
ing ; chloroform and chloral are useful ; chloroform must be 
used with great caution where cyanosis is great. 

PROF. F. WINCKEL, M. D., 

Says venesection is very rarely required. Only the most immi- 
nent danger will be an indication for resorting to this measure. 
Generally severe attacks become milder when profuse perspira- 
tion is established after the delivery. Excite copious evacuations 
by drastics, as jalap, aloes, ext. colocynth, and enemata of vine- 
gar and salt. As diuretics, tartaric acid, lemon juice, and flower 



424 COMPLICATIONS OF PARTURITION. 

of benzoin may be given. During the attack, chloroform may 
be used. If this be of no avail, strong doses of opium are of 
great value. Hypodermic injections, if the patient be unable to 
swallow. If there is great central congestion, leeches may be 
applied to the forehead or behind the ear. Cold compresses, ice- 
bags, sinapisms to the back of the neck, or even cold irrigation 
of the head, are advisable. Afterwards, stimulants to prevent 
collapse when threatened, tonics and nourishment for hydrsemia. 

WM. BERRY, M. R. C. S., EDINBURGH. 

For the treatment we have three periods : 

During pregnancy, when we must employ purgatives, bleeding, 
chloroform and chloral. 

During labor, chloroform and delivery. 

After delivery, chloral and bromide of potassium. A single 
dose of thirty grains each of chloral and bromide will usually 
prevent a recurrence of the convulsion, and produce quiet sleep. 
(Obst. Jour. Great Britain and Ireland, April, 1878.) 

ANGUS MACDONALD, M. D., EDINBURGH, 

(Obst Jour. Great Britain and Ireland, Aug., 1876,) regards as 
the most important, sedatives and anesthetics, and especially 
chloral, chloroform, ether and bromide of potassium. He trusts 
chiefly to chloral, giving it in doses of twenty-five grains every 
six hours, so long as the fits continue or threaten. He believes 
that it acts to dilate the arteriols, thus favoring the disappear- 
ance of ansemia in the brain ; acts as a sedative to the nervous 
system generally; allays muscular irritability and spasm, 
and thus tends to obviate cerebral congestions and extravasa- 
tions. 



PUERPERAL ECLAMPSIA. 425 

A. E. AUST-LAWRENCE, M. D., BRISTOL, ENGLAND, 

(Obst. Jour. Great Britain and Ireland, Oct., 1876,) feeds care- 
fully on milk diet for the first three or four days. Robust 
women who have eaten well up to confinement, require an ape- 
rient within forty-eight or even twenty-four hours after confine- 
ment. He prefers : 

314. R • Hydrarg. chlorid. mit., 

Pulv. rhei, aa gr. ij. 

Ext. belladon., 

Ext. opii, aa gr. \. M. 

For one pill, to be repeated every six or eight hours till the bowels act — 
generally three are required. 

He urges ergot for the first week or two, if the uterus does 
not involute as it should. 

H. B. WHITE, M. D., BROOKLYN, N. Y., 

Employed jaborandi in the case of a primipara at full term, 
highly anasarcous, and urine very scant. The drug was given in 
infusion, one drachm of the leaves being used and divided into 
three doses at short intervals. After the first dose, profuse 
sweating and salivation ensued. There were three convulsions 
prior to, and several after, delivery. The article was continued 
for three days, drenching the patient in perspiration. She com- 
pletely recovered. 

PROF. OTTO SPIEGELBERG, BRESLAU. 

This writer (Trans. Am. Gyn. Soc, vol. II.,) states that the 
treatment must be directed to effect three objects : 

1. The renal secretion must be restored. 

2. The arterial pressure must be diminished. 

3. Irritation of the nerve centres must be reduced. 



426 COMPLICATIONS OF PARTURITION. 

These results are most easily attained by (1) venesection ; (2) 
narcotics, and (3) if the patient be in labor, by its speedy com- 
pletion. 

Dr. G. M. Staples, (Iowa Med. Soc. Trans., 1880,) strongly 
advises hypodermic injections of two to three drops each of tinct. 
rad. aconit. and Norwood's tincture of veratrum viride. 

In the treatment of true eclampsia he places venesection first. 
As soon as the patient is seen, let the brachial vein be opened 
and from six to sixteen ounces of blood be taken ; and this be 
repeated unless its effects are decisive. In mere eclamptiform 
attacks, bleeding may be omitted. Narcotics should be adminis- 
tered soon after venesection. Among them, chloroform is the 
most advisable. The inhalation must be guarded, and only take 
place when the aura of another attack is observed. Its admin- 
istration may be combined with that of morphia or chloral ; the 
former subcutaneously, the latter by the rectum ; of morphia 
gr. J, of chloral gr. xliv. are sufficient doses to begin with. When 
there is coma, cold applications to the head are useful. In the 
paralytic stage, stimulants must be resorted to. Diuretics are 
useful of after-treatment during convalescence. 

KESUME OF KEMEDIES. 

Aconitum has been used to reduce the arterial pressure. It is 
highly praised by Phillips. 

Belladonna is recommended by some writers as a sedative to the 
nervous system in these cases. 

Benzoicum Acidum, as a diuretic, is valued as a prophylactic and 
to hasten convalescence. 

Chloral Hydras acts as an anaesthetic, is claimed to be similar to 
chloroform in its effects, to allay irritation of nerve 
centres, and to have a decided effect in controlling con- 
vulsions from whatever cause. It thus relieves the 
physician of the difficulty of deciding whether the 
cause be plethora or anaemia, whether to bleed or not. 
But, like bleeding, it is accused of producing anaemia. 
It may be conveniently given by the rectum in an 
enema holding in solution gr. xxx.-lx. Dr. Delatjny, 



PUERPERAL ECLAMPSIA. 427 

in a prize thesis, 1879, says that statistics show that 
puerperal convulsions treated by revulsives and anti- 
spasmodics show 50 per cent, of mortality, by blood- 
letting 24 per cent., and by chloral 13 per cent. 

Chloroform is acknowledged by all authorities to be of the great- 
est value either with or without venesection. For 
particulars as to its administration, see anaesthetics. 

Hydrargyrum. As there is a remarkable susceptibility to mer- 
cury in albuminuria, it should be given with great 
caution. 

Jaborandi and Pilocarpin have both been advocated for their 
diaphoretic effects by Massmann, Tehling, and 
others. (Centralblatt. filr Gyn., 1878.) The modus 
operandi is attempted to be explained on the Traube- 
Rosenstein theory of the convulsions. It is argued 
that the salivation and perspiration induced by the 
jaborandi or its alkaloid, relieve the excessive vascular 
tension. Two drachms of the fluid extract of jaborandi 
may be thrown into the rectum. 

Opium and Morphia. These are invaluable narcotics in this 
disease. They are best administered, opium by the 
rectum, morphia hypodermically. In sthenic cases, 
they should promptly follow venesection. In the Am. 
Jour, of Obstel, July, 1880, Dr. C. C. P. Clark very 
strongly advocates large doses of opiates. He avers 
they will prevent convulsions as surely as quinine will 
break up intermittent fever, and its effect is no less 
absolute even after convulsions have actually set in. 
One to three grains of opium should be given daily 
for the premonitory symptoms. When a convulsion 
has actually taken place, a grain and a half of morphia 
should be given hypodermically at once ; if a paroxysm 
occurs at any time after two hours, this dose should be 
repeated ; if the patient is in labor she should have 
another dose after eight hours in any event. These 
doses are perfectly safe, for the disease involves a re- 
markable tolerance of the drug. Evacuant treatment 
is allowable, and perhaps useful, but the opium should 
be the main reliance. When properly used, he has 
never seen it fail to ward off threatened eclampsia ; 
and he has never known a patient to die of the dis- 
ease when the drug had been given in season, in suffi- 



428 COMPLICATIONS OF PARTURITION. 

cient quantity, and in the proper manner. Others 
assert that the opium treatment gives a frightful mor- 
tality. {Half-Yearly Compend., July, 1880, p. 174.) 
Phosphorus. The intellectual hebetude which often remains after 
an attack of puerperal fever is best treated by phos- 
phorus in some easily assimilable tonic combination. 
Dr. E. T. Coleman recommends the following (Half- 
Yearly- Compendium of Med. Science, July, 1880) ■ 

315. R . Strychnise sulpli., gr. ss. 

Tinct. ferri chloridi, f. % ss. 

Acidi phosphorici diluti, f-Jjjss. M. 

Take thirty to forty drops in a wineglassful of sweetened water 
thrice daily. 

Potassii Bromidum is excellent as a prophylactic, gr. x. three 
to six times daily. In the attack, it may be advan- 
tageously administered between the seizures combined 
with chloral, of each, 3 ss. 

Sodii Bromidum acts similarly to the potassic salt, and may be 
used in its place. 

Veratrum Viride has been much discussed as an arterial sedative. 
Some practitioners claim that it entirely does away 
with the need of the lancet. It may be given in 
hypodermic injection of gtt. v.-x. of the fluid extract ; 
or by the mouth, in doses of gtt. v.-xxx., repeated as re- 
quired. If the pulse is full and above 80°, give the 
doses fearlessly. (Trans. Am. Med. Assoc, 1876, p. 240.) 
An ounce has been administered in twenty-four hours 
with success. Others fear the depressing character of 
this remedy, and do not favor it. 

GENERAL MEASURES. 

Cold, in the form of ice to the head, spinal ice-bags, etc., is 
valuable in states of coma. 

Diaphoresis, in order to produce a derivative effect and relieve 
the kidneys, has been attempted, both by means of 
drugs, as pilocarpin, and by Jacquet, by enveloping 
the body in wet sheets wrung out in quite hot water. 
This can only be relied upon in mild cases, and rather 
as a prophylactic. 



PUERPERAL ECLAMPSIA. 429 

Purgatives diminish arterial tension, draw congestion from the 
renal regions, and are a rational mode of treatment. A 
full dose of calomel and jalap may be given if the pa- 
tient is able to swallow ; otherwise a drop of croton 
oil may be applied to the back of the tongue. In both 
cases an enema of castor oil and oil of turpentine, one 
tablespoonful of each in chamomile tea, should be 
thrown up the rectum. (Spiegelberg.) 

Transfusion has been suggested by some writers, to follow ven- 
esection. Its value is undetermined. 

Venesection is, in sthenic cases of true eclampsia, the most val- 
uable of all remedial measures. See p. 420. It is 
not out of place, even in chloransemic cases. 



430 COMPLICATIONS OF PAKTUKITION. 

PUERPERAL MANIA. 

A. H. KUNST, M. D., WESTON, W. VA., 

In a paper read before the State Medical Society, gives the treat- 
ment as follows : His belief is that the tendency in such cases is 
towards exhaustion, hence depleting measures must be regarded 
with great circumspection; rarely is venesection justifiable. At 
the onset, if the secretions are locked up, a dose or two of calo- 
mel or blue mass, and warming laxatives, may be given accord- 
ing to circumstances, with great care to prevent a drain. If there 
be increased heat of the scalp, apply cold to the head. A warm 
bath in the evening will be useful and soothing, and promote 
sleep. The best hypnotic is a combination of chloral and bro- 
mide of potassium. Symptoms may, however, indicate hyoscy- 
amus, conium, camphor, monobromated camphor, opiates, etc. 
Tranquillity should be invited and encouraged by the attentions 
of a trained nurse, and all interference prohibited. Husband the 
strength, and if necessary, use the camisole to restrain too con- 
stant movements. Diet should be nutritious and generous, and 
easy of digestion. Iron, quinine, phosphorus, etc., should be 
employed as indicated. If acute delirium occur, and she refuses 
food, use the oesophagus tube, and inject twice daily beef-tea, and 
milk, and eggs alternately. 

The moral management is important, and she should be guarded 
against self-injury. Generally, the wiser plan is to remove her 
from her familiar surroundings, to change the train of ideas. 
Interviews with husband and friends should be restricted. Often 
she regards them as her enemies, and their visits add to the 
trouble. Exercise in the open air, with some light, congenial 
employment, is of great value. Convalescence should be aided 
by a few weeks at an agreeable resort, or pleasure traveling. 



PUEEPEKAL MANIA. 431 

S. PUTNAM, M. D., MONTPELIEK, VT., 

Says, in the Transactions of the Vermont State Medical Society, 
1879: 

First learn betimes the vulnerable points and tendencies of 
patients, and regulate their hygiene and medication accordingly. 
Should a latent albuminuria be found, let the patient live upon 
milk diet ; use the warm sitz-bath at night, followed by abundant 
frictions to the back and limbs. In the morning, cold or tepid 
sponging, with friction, to be followed by walking, or carriage 
exercises. At lying-in, avoid as far as possible the causes of 
anaemia, prostration, irritation and excitement. 

Should the patient be unable to sleep, make the conditions the 
most favorable to secure that result, and if sleep does not occur, 
use chloral, morphia and camphor, or whiskey in quantities ordi- 
narily adequate to produce that effect, and we shall seldom have 
puerperal mania to treat. But should a threatening case explode, 
notwithstanding your care, perhaps a cathartic is needed, espe- 
cially if constipation exists, after which a more efficient use of 
anodynes, stimulants and tonics may succeed. Should they not, 
and the delirium be violent, aconite, veratrum or digitalis might 
be used, or even anesthetics. When ursemic delirium or stupor 
is evident, use ten grains nitrate of potassa, one drachm nitrous 
ether, and five drops of dilute nitric acid in water, every four 
hours ; or instead, when insomnia persists, ten or fifteen grains 
bromide potassium every two hours, alternately with twenty 
drops tinctura ferri chloridi. Meanwhile, nutrients, stimulants 
and tonics are to be given as needed. 

PROF. WM. LEISHMAN, M. D., GLASGOW. 

We can scarcely doubt that when there are indications of cere- 
bral disturbance, much may be done to ward off an attack, par- 
ticularly where there is a hereditary taint, or where insanity has 
been present at previous confinements. 

It must be remembered that it is essentially a disease of de- 






432 COMPLICATIONS OF PARTURITION. 

bility, and hence blood-letting must be used, if at all, with very- 
great caution, for we may thus precipitate a fatal result. It 
should only be used in actual phrenitis. 

Gastro-intestinal disturbance will require from the first prompt 
attention. Relieve the overloaded bowels, and keep them cleansed. 
Aloetic purgatives are very appropriate. Where the powers are 
not low, and there is a foul tongue, offensive breath, a yellow eye, 
an emetic of ipecacuanha may be given. . Gooch believed this, 
and most modern writers agree. But, of course, this is contra- 
indicated when the face is pale, the skin cold, the pulse quick 
and weak. When much vascular excitement presents, cold to 
the head, or even better, laving the forehead and temples with 
warm water, after which there is a refreshing coolness, may pro- 
duce the desired effect. Tartar emetic very guardedly, or tinc- 
ture of aconite, or of veratrum viride, are useful. 

The nervous sedatives are most important, and at the head of 
the list is opium, the sheet anchor. It must be given in very 
large doses. If there is difficulty in giving it, introduce a sup- 
pository into the rectum, of one or two grains of morphia. 
Remember that Ttjke says that opium or other narcotics are not 
to be used in acute mania. Chloroform has been employed bene- 
ficially ; the patient being placed fully under its effect, and so 
kept for a season. Hyoscyamus, with ether or ammonia, and 
Indian hemp, have been used for the same purpose. Gooch's 
favorite was camphor. Chloral has now superseded opium, and 
is a most valuable article. The warm bath is an excellent 
sedative, and may succeed in the failure of drugs. Procure 
sleep, and the patient may at once recover. 

PROF. W. S. PLAYFAIR, II. D., OF LONDON. 

Maintain the strength of the patient, calm the excitement, rest 
the disturbed brain. Over-active measures, as bleeding, blister- 
ing the shaven scalp, and the like, are distinctly contra-indi- 
cated. 

Abundance of nourishment comes next. Give solid food prin- 



PUERPERAL MANIA. 433 

cipally, reserving beef-tea and brandy later. Food must be 
given forcibly, if necessary. 

Stimulants increase the excitement, and are only useful in 
melancholia. 

Keep the bowels well cleansed. 

Procure sleep; nothing is so valuable as chloral, alone or in 
combination with bromide of potassium ; 15 to 30 grains at bed- 
time rarely fails to procure sleep; give this in an enema, if the 
patient will not swallow. 

Opiates are apt to do more harm than good. 

Blandford, on this point, says he believes opium never does 
good, and may do great harm. This applies equally, whether 
by the mouth or hypodermically. Often, after an opium sleep, 
the patient quickly rouses, and all is worse than before. In 
melancholia, in moderate doses, it may be given with advantage. 

The prolonged use of the warm bath, say at 90°, for half an 
hour, has acted well as a sedative. The wet pack is equally 
good, and is more readily applied in refractory cases. 

ALFRED MEADOWS, M. D., LONDON, 

Takes almost precisely the same ground. Remove all supposed 
sources of irritation ; quiet the nervous system ; support the 
strength. Oppose constipation with 20 or 30 grains of jalap 
powder and two to five grains of calomel, followed by saline 
aperients. Rigby advised antimony with calomel and ipecacu- 
anha, as too speedy to depress, and acting as a rapid purge ; it 
acts, she falls asleep, perspires freely, and wakes greatly re- 
freshed. As a rule, eschew opiates; they increase the irritability 
and favor cerebral congestion. Chloral may be given in doses 
of 20 to 60 grains, induces sleep without excitement or depres- 
sion ; henbane and chloroform are of great service. White helle- 
bore has been recommended, and Indian hemp also. Hydrocyanic 
acid in doses of five minims of the dilute acid, every four hours, 
has been found of great value. 

Vigilance must be great. Support with beef- tea, wine, etc. 

28 



434 COMPLICATIONS OF PARTURITION. 

PROF. FORDYCE BARKER, M. D., NEW YORK. 

Bleeding is useless, even injurious, as are vascular sedatives, 
except where there is also a latent local inflammation. Laxatives 
and emetics should never be given, except when positively re- 
quired. 

Insomnia, a striking feature, would suggest opium, but it will 
not, in any doses, cut short an attack, but may be of service 
where there is latent pelvic peritonitis. 

Allay brain excitement by restoring exhausted nerve power; 
improve the nutrition of the brain by easily assimilated food. 
Tonics are of great service, as tinct. of chloride of iron, chlorate 
of potassa, and the sulphate of berberina. The latter is prefer- 
able to quinine, as it has much less tendency to induce cerebral 
congestion. 

Induce sleep. Neither opium nor bromide of potassium will, 
as a general rule, do this. Chloroform also has disappointed 
nearly all. Chloral is of immense value; it does not interfere 
with any of the organic functions, is not followed by any un- 
pleasant secondary effects like opium, and never fails to produce 
sleep. This is prolonged for hours, and if interrupted, the 
patient falls asleep again without a renewal. It is best given in 
doses of 15 or 20 grains well diluted, and repeated every two 
hours till the effect is produced. 

Combat all complications. Give laxatives for constipation, 
diuretics for deficient renal secretion. If cerebral erethism arise, 
shown by the flushed face and red eyes, give bromide of potas- 
sium, 20 to 30 grains every six hours; but at night, for sleep, 
suspend this and give chloral. Watch for local inflammations, 
and employ appropriate remedies. 

In puerperal mania, accompanied with high fever, restless- 
ness, head symptoms and scanty secretion of milk, aconite acts 
speedily and markedly if given soon after the chill. (Phillips.) 

When the delirium is wild and furious, but intermittent, with 
scanty secretion of milk, etc., stramonium is useful. The nerv- 
ous system is relieved, the flow of milk renewed, and sleep 



PUERPERAL MANIA. 435 

restored. From a quarter to a half grain of the extract in 10 to 20 
minims of the tincture may be given every three or four hours 
until relief is obtained. The lochia, etc., should be watched, and 
the patient's powers sustained by nutrition and stimulation. 
(Phillips.) 

In puerperal hypochondriasis, Sir Jas. Y. Simpson, after fail- 
ure with many remedies, used tincture of cimicifuga, fifty drops 
a day. In eight or ten days the change for the better was mar- 
velous, and the patient was completely restored to her former 
health and spirits. 

Prof. Bartholo w also speaks of its value. 

DR. A. J. C. SKENE, N. Y. 

In an article on the treatment of diseases of the reproductive 
organs among insane women, {Archives of Medicine, Feb., 1880,) 
this writer observes that it is based upon the general principles 
which guide us in ordinary practice. There are, however, cir- 
cumstances peculiar to this class of patients which must, of neces- 
sity, modify our treatment. 

In the management of cervical endometritis, it is necessary 
to use means that do not require frequent repetition. On that 
account the hot water douche (a most valuable remedy) can- 
not be used, because these patients will not permit the nurse to 
treat them, nor will they use it themselves, except in rare cases. 
There is the same objection to the use of the cotton and glycerine 
tampon, which requires to be renewed every day. In such cases 
Dr. S. has used with advantage an application of equal parts of 
tincL iodine and carbolic acid once a week. This is sedative, and 
also changes the abnormal action of the mucous membrane, 
causing a diminution of the leucorrhoeal discharge, the erosion 
of the surface disappearing, not by being replaced by cicatricial 
tissue, but by the restoration of normal epithelium. When im- 
provement begins to appear it is well to lessen the proportional 
quantity of the acid. 



436 COMPLICATIONS OF PARTURITION. 

Vaginitis is also a difficult disease to treat among insane 
women, owing to the same objections to the vaginal douche. 
Little progress can be made in the management of this affection 
without thorough cleanliness, and that is difficult to obtain 
among insane patients. In fact, vaginitis and vulvitis occur 
oftener in this class of patients than among those of sound mind, 
owing, apparently, to want of care in keeping the parts clean. 

The treatment adopted in these cases consisted in first cleans- 
ing the membrane thoroughly with a sponge, and then applying 
a mild solution of nitrate of silver, or sulphate of zinc with fluid 
ext. of hydrastis canadensis and water, and then introducing a 
tampon of marine lint. This tampon is changed for a new one 
every two or three days, until the inflammation subsides. This 
is sufficient to cure most cases of vaginitis without any other 
treatment. It separates the inflamed surfaces, and by absorbing 
the secretions, keeps the parts perfectly clean. The tar which it 
contains is one of the most useful remedies in inflammations of 
mucous membranes, and, besides, fulfills a modern demand in 
surgery in being antiseptic. This method of treating vaginitis 
has been tried in general practice, and answers well, but it is 
among the insane where its value is most marked. 

Endometritis polyposa, or fungosq, with the menorrhagia which 
is caused thereby, is quite a common affection among the insane. 
To meet the indications and the circumstances which the accom- 
panying insanity gives rise to, he has adopted, with satisfactory 
results, the following method of treatment : 

Having made a positive diagnosis, a small curette or scoop, 
having a flexible stem, is carried into the cavity of the uterus, 
and the whole of the fungous material broken down and re- 
moved. This simple operation is often followed by complete 
recovery. Sometimes the polypoid growth returns, and a rep- 
etition of the operation is necessary. In very few cases it has 
returned again and again, but has finally yielded to the use of 
bichloride of mercury, given in the usual doses, and the applica- 
tion of tincture iodine and carbolic acid after the use of the 
curette. There is nothing new in this method of treating the 



PUERPERAL MANIA. 437 

disease in question, except in omitting dilatation of the cervix by 
tents as a preliminary. This is entirely unnecessary, and should 
be avoided, because it is painful and dangerous, while the use of 
the blunt scoop is less likely to give after-trouble than any other 
form of intra-uterine treatment. The methods of treating this 
affection, given in the books, are first to dilate, use the curette, 
and finally use some caustic or alterative application to the whole 
endometrium. This requires that the patient should be confined 
to bed several days, care being taken to prevent the development 
of inflammation ; and with all there is danger. Such practice is 
impossible among the insane. 

For laceration of the cervix uteri, the success of the operation 
depends to some extent upon the details of after-treatment, sitch 
as rest in bed and cleanliness. That is difficult to obtain among 
insane women, but in lieu of that he has employed a method of 
operating which gives fair results, even when the patient goes 
around during the healing process, to wit, the use of silk sutures 
and the lint tampon in place of the douche. 

The advantage is that the sutures cannot wound the vagina 
like the ends of a silver-wire suture, and the tampon supports 
the uterus and guards against putting a strain upon the sutures 
when the patient moves or sits up. This method is well adapted 
to practice among the insane. A question may be raised as to 
the propriety of leaving a silk suture in the cervix during the 
time requisite for healing. The constant heat and moisture to 
which the 'suture is exposed, certainly favors decomposition of 
the silk, and if that should occur the suture would cause suppu- 
ration. No such results need be feared when the silk is properly 
prepared by immersing it for several hours in a composition of 
melted wax, salicylic and carbolic acids. 

The pelvic pain or neuralgia, which arises from circatrices of 
the cervix and vagina, is often very annoying, and calls for treat- 
ment. Marked relief follows after dividing the bands of cica- 
tricial tissue. 

Displacement of the uterus, i. e., prolapsus and versions, can 
be treated with good results, excepting when there is anatomical 



438 COMPLICATIONS OF PARTURITION. 

or functional imperfections of the perinseum. The displaced 
uterus can be readily restored and a pessary adjusted while the 
patient is anaesthetized. It is necessary to frequently examine 
such cases while wearing pessaries, because they may suffer with- 
out complaining. 

The most important difficulty is encountered in the manage- 
ment of displacements among those having imperfect perinsei. 
Pessaries or supporters held in place by being fastened to the 
body cannot be used, and on that account we are limited to intra- 
vaginal pessaries, which require the presence of the perinseum. 
To restore a lacerated perinseum would be easy, but to secure 
the after-treatment necessary to a good result is often impossible. 

Flexion of the uterus, in its various forms, gives rise to 
much suffering when the menstrual function continues, and dys- 
menorrhoea is a common result. In quite a number of patients 
with flexion there is amenorrhoea, and in such, flexion alone is 
presumed to give no trouble. There is no reason for believing 
that a flexion unassociated with any other disease of the uterus 
would give rise to disturbance of the brain or nervous system 
in a patient who does not menstruate. But when the menses 
recur, and are painful, the probabilities are that the flexion is 
the cause of the dysmenorrhcea, and it should be relieved if 
possible. Knowing how difficult flexions are to cure, when the 
circumstances are favorable, it need hardly be stated that the 
treatment of such deformities among the insane is often very 
unsatisfactory. The most daring gynecologist would hesitate 
to use a stem pessary, or perform division of the cervix in a 
patient who could not be well controlled during the after- 
treatment. In flexion of the cervix division might be practiced 
in patients not too violent and uncontrollable. As a rule, how r - 
ever, the treatment in such cases is limited to subduing any exces- 
sive irritability of the uterus, and securing a sufficient size of 
the canal by dilatation or incision, if necessary, and in cases 
of forward flexion of the body, much might be gained by 
straightening the uterus and keeping it so by means of Thomas' 
anteflexion pessary. 



PUERPERAL FEYER. 439 



PUERPERAL FEVER (PUERPERAL SEPTICEMIA, 
SAPRiEMIA * PUERPERAL PYEMIA.) 

DR. R. PARK, OF GLASGOW. 

Ill a careful study of the treatment of the post-partum fevers 
[Glasgow Medical Journal, Oct., 1880,) this practitioner states 
that the successful treatment of the group of pyrexial diseases 
hitherto known under the common term " puerperal fever," 
lies in — 

A. The successful treatment of the initial rigor, when pres- 
ent, with the view specially of limiting its duration. The thera- 
peutic means at our command for this end are the hot blanket- 
bath and local derivatives, hot drinks, and the hypodermic in- 
jection of pilocarpiu nitrate with or without morphia and bella- 
donna, according to the presence or absence contemporaneously 
of peritonitis or some other acute inflammation. 

B. The limiting of reaction after the rigor and derivation of 
local congestion to non-vital parts ; by venesection, digitalis, Nie- 
nieyer's powder, salicylic acid, quinine, cataplasms, and poultices. 

C. Cleansing prima? vise (unless contra-indicated,) palliation 
of vomiting, purging and pain, if present, and cleansing and 
disinfection of genital canal and uterus. 

D. By systematic treatment adopted for the palliation of the 
most prominent complication present in individual cases, but 
most specially by reduction of hyperpyrexia, when present, 
and administration internally of turpentine and belladonna in 
large doses, more particularly where the peritoneum and uterus 
are inflamed. 

E. Surgical means of relief and cure. 

The initiatory rigor we are rarely called upon to deal with, 
because it is often absent or little pronounced, and when severe, 
it is often over before we have time to reach the bedside. Our 
main object in dealing with it is to "cut it short," for the longer 

*Saprmrnia is poisoning not by an organism multiplying in the blood, but by 

^ha fil.pmiVn] v%vnrlHr>+Q of rMifvtrJ. rlp^n"T->oaitinn r^p (seiner intO it. 



440 COMPLICATIONS OF PARTURITION. 

the rigor lasts the more intense and unmanageable are the inter- 
nal phlogcses likely to be, and the higher the pyrexia. Hot de- 
mulcent drinks, hot jars and bottles applied to the body and 
extremities and increased bed-clothing are the most accessible 
means. When possible, a diffusible stimulant with two or three 
grains of opium in gum, or Dover's powder, or still better, a 
hypodermic injection of morphia (one-half to one grain) should 
be administered at once. 

Probably the best means we now have of effecting the object 
in view is by hypodermic injection of pilocarphi nitrate. By its 
powerful action upon the circulatory organs, the skin, and 
emunctories generally, it is not only likely to cut short the most 
severe rigor, but, in an almost miraculously short space of time 
to liberate the excretions of skin, salivary glands, liver and kid- 
neys ; and thus exert a derivative effect upon all internal con- 
gestions. The dose should be at least one-quarter of a grain to 
commence with, to be repeated in fifteen minutes, if all the 
physiological effects of the drug are not obtained by that time. 
Morphia may be injected simultaneously if localized pain has 
preceded or accompanies the rigor. The morphia should not be 
in more than a one-sixth grain dose, however. 

The symptom next in importance, if not in frequency, as a 
source of danger, is hyperpyrexia; and it is now an established 
rule of treatment to control this by the application of cold in 
various forms; as by an ice-bag to the head, alternating with a 
spinal ice-bag ; by sucking ice; or the application continuously 
of ice-cold cloths to the chest, abdomen and legs. Dr. Wilt- 
shire, again, advocates dry cold, applied to the body in tin pans 
made for the purpose, and also in India-rubber bottles. How- 
ever carried out, the method must be directed to the hyperpy- 
rexia exclusively as a symptom, and must be carried out with 
firmness and determination, and accompanied by the administra- 
tion of liquid food and stimulants, together with the fulfilling of 
any other indication which present symptoms may render 
necessary or obvious. 

Of remedies used internally for the same end, quinine and 
Warburg's tincture stand first. 



PUERPERAL FEVER. 441 

Salicylic acid has been recommended by several practitioners 
by reason of its efficacy in rheumatic fever. The writer believes 
that he has had good results from using salicylate of soda, com- 
bined as in this formula : 

316. R . Sodii salicylatis, 3j ss. 

Liq. amnion, acet., j; iij. 

Liq. morph. hydrochl., 3 iij. 

Spt. cliloroformi, % i. 

Aq. menth. pip., ad |j x. M. 

A tablespoonful every four hours. 

For hyperpyrexia also, Nierneyer's antipyretic powder is sec- 
ond to none. > 

In cases where great asthenia is present without hyperpyrexia, 
where a profound alteration of the circulating fluid has taken 
place, rendering reaction difficult, if not impossible — and in- 
flammatory lesions, when present, are of a languid and ill-pro- 
nounced type — an asthenia accompanied by great depression, 
precordial sinking, and uncountable, feeble pulse, stimulants 
and opium are the remedies most to be relied upon. If good is 
to be got from them, they also must be used heroically and 
methodically. The amount of alcohol which such patients can 
consume without toxic effects is not less wonderful than the 
amount of opium which may be given to them with benefit. 
The spt. terebinihince has given most satisfactory results. It 
is certain that, when peritonitis and tympanites form 
prominent features, or occur independently, the spt. tere- 
binthinse administered in some form or combination, and given 
in large doses frequently, is the most invaluable medicine. The 
formula which Dr. P. most frequently uses, is this : 



317. R . Spt. tereb. rect, 
Ovi vitelli, 




Mix well and add : 




Muc. gum mi acacise, 


fiv. 


Syr. limon., 
Tinct. belladon., 
Liq. morph. hydrochl., 
Ess. menth. pip., 
Aq. chloroform., 


Sij- 

£iv. 

ad 5 x. 


tablespoonful every three hours. 





M. 



442 COMPLICATIONS OF PARTURITION. 

Whenever peritonitis, either general or localized, is a promi- 
nent symptom, belladonna and opium are the most reliable 
agents with which to deal with it. Opium has been long known 
to exert «a powerful influence over peritonitis, but somehow it 
would appear as if the knowledge had not been properly appre- 
ciated or acted upon. In order to get benefit from its use in 
acute and dangerous cases, it must be given in doses sufficient to 
'produce arid maintain narcotism. Unless this is done, tempo- 
rary benefit only will ensue. The fear of narcosis may practi- 
cally, in dealing with these cases, be dismissed from the mind. 
There is no necessity to produce too profound narcosis, and so 
create alarm needlessly; but it is absolutely necessary to main- 
tain a prolonged narcosis, once it is induced. Dr. P. has repeat- 
edly injected subcutaneously as much as three grains of morphia 
hydrochlorate (Glas. Med. Journal, July, 1876,) incases of post- 
partum peritonitis, without inducing even moderate narcosis, but 
with marked and immediate relief to harassing pain. Experi- 
ence teaches that, having promptly subdued pain and distress by 
injection of a sufficient dose of morphia subcutaneously, the ano- 
dyne influence (and stimulant and sustaining powers) of the 
drug should be maintained by repeated small injections, or by 
its administration in combinations, by the mouth or rectum. 

The usual effects, when thus given, are disposition to sleep, 
but not profoundly, contracted pupil (not always, nor even gen- 
erally, when hypodermically administered,) perspiration, often 
profuse, sometimes a red, blotchy eruption, (?) diminished fre- 
quency of respiration, subsidence of pain and tenderness, slight 
suffusion of eyes, and, after a time, reduced pulse. The ease 
with which a patient can be roused from sleep when a dose is due, 
and the state of the respiration, are the guides as to whether the 
dose should be given or not. If the latter be reduced to twelve 
in the minute, or should be very irregular, or sighing, the dose 
should be diminished or withheld. The respiratory function 
gives the most certain and reliable indication of where danger is 
present. 

Belladonna, as a remedy for peritonitis, whether idiopathic or 



PUERPERAL FEVER. 443 

post-partum is of more recent date ; but recent experience leads 
to the belief that it is even more specific than opium, when used 
systematically and in what is considered large doses. When 
given alone, it is necessary, as in case of opium, to induce and 
maintain its physiological effects ; and when given in combina- 
tion, it is best given so that its effects shall rise superior to those 
of the agent with which it is combined. Thus, in prescribing it 
with opium, one of the most effective forms in which it can be 
given is with Dover's powder, as thus : 

318. B. Extract, belladonnse, gr. xij. • 

Pulv. ipecac, comp., gr. xlviij. M 

Make twelve pills. One every second hour. 

The physiological effects of the belladonna are fully produced 
after the third or fourth dose, when the interval between the 
doses may be lengthened. 

The delirium and indistinct vision are the guides. After their 
production they should be maintainad till such time as the more 
urgent symptoms of the fever have passed away. 

For the relief of the pain of peritonitis, poultices have been 
prescribed as a routine. This is a practice, however, which, the 
writer feels is highly dangerous and cannot be too severely de- 
precated, as, if the pain be due to an incipient peritonitis, it is 
amazing with what rapidity it spreads under the fostering warmth 
of a hot poultice. Care must therefore be taken to make as 
accurate a diagnosis as possible of the cause of the pain ; but, at 
all events, to make sure it is not due to an incipient peritonitis. 
In cases where it can reasonably be construed to be due to any 
other cause, as, e. g., painful and partial uterine contractions, 
retention of lochia and clots, cellulitis, metritis, etc., poultices 
will at once contribute to the relief of the pain as a symptom, 
and, in some instances, to the removal of the cause by resolution 
or suppuration, etc. And, again, in cases of completely devel- 
oped peritonitis, light and often-changed poultices are of infinite 
value for the soothing of pain and promotion of resolution under 
systemic treatment. 



444 COMPLICATIONS OF PAETUEITION. 

What has just been written regarding poultices might be 
repeated with regard to leeching. In cases of peritonitis, unless 
in the rare case where an adhesion has already formed, leeching 
only increases the inflamed area and the rapidity of extension, at 
the same time that it lowers the vires vitaa. When abstraction 
of blood can be borne, as has been previously stated, it is best 
done by venesection, and a rapid withdrawal of sufficient to 
affect the pulse — the effect being maintained afterwards by suit- 
able medicines, as, e. g. y digitalis alone, or in combination, as in 
Niemeyer's powder. 

The induction or restoration of the lacteal secretion is fre- 
quently an object which the physician is desirous to attain, as 
much for the sake of the reflex action so obtained thereby on 
the womb as for other reasons. The hypodermic injection of 
pilocarpin nitrate is likely to prove a valuable means to this 
end ; and where there is hardness and congestion, with tender- 
ness of the mammae, friction with vaseline is at once an elegant 
and efficient adjuvant to other means in more ordinary use. 

When a zymotic or cadaveric etiology is clearly made out, or 
even when there is a prima facie case in favor of it, the infant 
should be withheld from the breast; in other cases the infant 
may more properly be put to the breast, always provided that 
the patient herself desires it, and it does not fatigue her. Under 
these circumstances the infant derives no harm, and the mother 
benefits from the rousing of her sympathetic system into more 
perfect action as well as from a fuller and speedier establishment 
of the lacteal secretion. When, however, great asthenia is pres- 
ent, or a fatal termination seems imminent, the fatigue of endeav- 
oring to suckle her infant might only hasten collapse, and other 
means should be adopted for soliciting or maintaining the secre- 
tion. 

In cases where it is suspected that there are in the womb 
either an adherent shred of placenta, foetid membranes, a decom- 
posing clot, or vitiated lochia, the very first and foremost thing 
to be done is to explore the interior of that organ and remove 
the contents. The most satisfactory way of doing this is to pass 



PUERPERAL FEVER. 445 

the previously anointed hand into the womb, and carefully re- 
move therefrom any solid cause of offence; and at the same 
time, and before removing the hand, to have the interior well 
syringed with a disinfectant solution. The womb may be ex- 
plored in this way as late as three weeks post-partum. 

Uterine oneiroscopy, however, is such a very uninviting pro- 
ceeding, and so obnoxious to the patient under the circumstances 
(post-partum) that it is never likely to become a routine practice 
even in presence of febrile symptoms. As a general rule syring- 
ing will be resorted to, not only as a prophylactic, but as a cura- 
tive measure. 

Tympanites is a symptom which frequently calls for separate 
treatment. It is most frequently present as the result of a par- 
alyzed condition of the bowels in general peritonitis, but it may 
occur in the course of any post-partum fever independently of 
peritonitis. The turpentine mixture, of which a formula is 
given above, is the best remedy so far as drugs are concerned. 
It may be fitly administered as an enema likewise. 

Puncture of the colon in the right iliac fossa seems to be the 
only treatment which is effectual, as it is also the best. It is 
necessary that the aspirating needle should not be of too small 
a diameter, else the result may be disappointing, a fresh gaseous 
secretion or formation taking place as fast or faster than escape 
takes place. It is well also to have a broad bandage passed 
round the body before the needle is introduced, so that pressure 
may be brought to bear on the tympanitic abdomen, for atmos- 
pheric pressure does not seem to be sufficient in some cases to over- 
come the inertia of the intestinal and abdominal walls. As it 
has been proved over and over again, to be quite a safe operation, 
no one should rest satisfied until the distension is relieved. 

Gastro-bilious symptoms are sometimes so prominent a feature 
of post partum fever that they have given rise to the erection of 
a distinct type, termed the gastro-bilious (puerperal intestinal 
irritation of Locock.) When the symptoms supervene early, the 
indications are promptly to aid the efforts of nature by exhibi- 
tion of smart stimulating emetics or cathartics, followed by 



446 COMPLICATIONS OF PARTURITION. 

demulcents, and then derivatives and sedatives. The hypoder- 
mic injection of pilocarpin, accompanied by administration of 
bismuth and hydrocyanic acid and morphia, will probably fulfill 
the latter indications better than any other method that can be 
thought of. Hot applications to the surface will a be suitable 
adjuvant, with the addition of capsicum or mustard cataplasms 
over the stomach if relief is not obtained by these means in the 
course of a couple of hours. Then, as soon as the chylopoietic 
tract is in repose, the mist, tereb. c. belladonna should be ad- 
ministered. 

Hydrosis was the title given by Ramsbotham to what he con- 
sidered a distinct form of post-partum fever. It is regarded by 
Leishman as a symptom only. Certainly it is the symptom in 
many cases; but, except for the adynamia with which it is ac- 
companied, it does not call for very special treatment. The 
turpentine and belladonna treatment is peculiarly applicable, as 
the one stimulates whilst the latter modifies the excessive sweat- 
ing. ■ The adynamia must also be relieved additionally by spe- 
cially devised nourishing soups and enemata, and the administra- 
tion of wines rich in tannin. 



This distinguished teacher states that during the currency of 
puerperal septicaemia or poisoning there is the possibility of a 
cure, almost sudden, by removing the foetor or stopping the sup- 
ply of the poison. Nothing is more striking or more gratifying 
in the whole practice of medicine than this sudden recovery. 
A patient in the most alarming condition, apparently within a 
few hours of death, is appropriately treated, and within a few 
hours alarm has entirely subsided. It is not in lying-in women 
alone that such cases are seen ; but sapreemia is more frequently 
observed in them than in others. 

Saprsemia is treated earnestly, even heroically if necessary, 
with a view to its own cure, and with a view to the prevention 
of the complications, inflammatory, septicemic, or pysemic, 



PUERPERAL FEVER. 447 

which it is very likely to bring in its train. Heroic treatment 
may be required to reach the remotest part of the genital tract in 
search for decomposing matter, or to ascertain that there is noth- 
ing but putrid lochia in the case. Mere vaginal washing may 
suffice, or intra-uterine washing, or the volsella may be passed 
into the uterus to grope for the decomposing structure, or with 
the same view a finger or fingers may be passed, or even the 
whole hand ; and it may be necessary to dilate the cervix pre- 
liminarily. Most of this may be done without an anaesthetic, 
but where the hand is to be introduced into the vagina, the pre- 
vious induction of anaesthesia is desirable. 

The lotion which Dr. Duncan always uses is the carbolic, of 
the strength of 1 in 40, or occasionally 1 in 30. It is used 
tepid or warm. In conducting the operation it is necessary to be 
very gentle, to avoid the introduction of air into the passages, 
and to see that the fluid runs out freely. If the os uteri externum 
and internum are not widely open, a pipe with double current 
should be used. The whole proceeding should cause little or no 
pain, and, for an ordinary washing, a pint or a pint and a half 
may be passed. But if the discharges are copious and foetid, 
more may be required, and the rule is to continue the injection 
so long as it comes away foul or perceptibly foetid. Of course, a 
bowl is to be so used as to receive all the lotion as it is discharged, 
in order to save the bed-linen from being wetted. When the 
uterus is washed out the medical attendant conducts the opera- 
tion, but vaginal washings may be left to the nurse. The wash- 
ings are to be repeated from twice to four times a day if the 
foetor persists in the discharges. After the fcetor is suppressed, 
twice a day is sufficient. If the discharges become natural, and 
if the symptoms of saprsemia disappear, the washings are stopped. 
In any case they are required only for a few days. 

Ice is useful to allay thirst, and also for the nausea and vomit- 
ing, which is a common symptom of peritonitis. For the exces- 
sive and painful flatulence often present charcoal in teaspoonful 
doses may be given in water once or twice daily ; or turpentine, 
in ten-drop doses, three or four times a day in any appropriate 



448 COMPLICATIONS OF PARTURITION. 

vehicle. Opium may be almost always given with advantage. 
With all these the great points remain of good nursing, careful 
feeding and prudent stimulation. 

JAS. G-. GLOVER, M. D., LONDON, 

In the Lancet, Feb. 1st, 1878, includes under the term "puerperal 
pyrexia/' all cases of high temperature not associated with obvi- 
ous external inflammation, as in the breast, or with obvious infec- 
tion from the common infectious diseases. Presumably the local 
leison is uterine or peri-uterine, for there is almost always more 
or less pain in and tenderness over some part of the uterus, with 
a good deal of abdominal distention. There is also generally a 
quick pulse, and the thermometer, which is an invaluable guide 
in such cases, shows a high temperature. In no case has he seen 
suppuration, and the patient has got well gradually. 

He sums up the treatment : First, a dose of quinine and 
iron every three or four hours. The following is a good form in 
which to give these : 

319. R • Quinise sulphatis, gr. ij. 

Ferri chlor. tinct., 

Sp. chloroformi, aa TT\,x. 

Syrupi simp., f. 



Aquse destil., f.^f j. M. 



For one dose. 



Secondly, a dose of bpium every three, four, six, or eight 
hours, according to the pain, without ipecacuanha, which may 
set up sickness, and without calomel, which may set up unneces- 
sary irritation of the bowels. The dose of opium, say half a 
grain, is best given in a small pill. Thirdly, a large linseed or 
bran poultice over the stomach, repeated every three or four 
hours. A little laudanum in it often adds much to its soothing 
effect. Fourthly, and specially, vaginal injections, at least twice 
a day, of warm water with a little Condy's fluid in it. The diet 
should consist of good beef-tea or chicken-broth, with generally 
a small regulated allowance of brandy, a dessertspoonful every 



PUERPERAL FEVER. 449 

three or four hours. Sometimes the brandy is best given with 
arrow-root. 

HUGH MILLER, M. D., OF GLASGOW. 

Excessive and Septic Lochia! Discharge. This teacher, in a 
clinical lecture, reported in the Edinburgh Medical Journal, Nov., 
1878, recommends the following prescription in cases in which 
there is an excessive discharge, accompanied by a relaxed condi- 
tion of the uterus. He administers one drachm doses of liquid 
extract of ergot, repeated every three or four hours, and 

320. R. Quiniae sulph., ^ss. 

Acidi hydrobromici, gvj. 

Aquam, ad J ij. M. 

Dose, teaspoonftd in water three times a day. 

By this method large doses of quinine may be given without 
causing headache. 

In septic cases Dr. Miller advises the employment of sulpho- 
carbolate of potassa, in the form of powders, in doses of 10 to 15 
grains internally three times a day. When the discharge is sus- 
pended, the treatment consists of turpentine stupes applied over 
the lower part of the abdomen, with the addition of warm moist 
cloths, or of sponges pressed out of hot water, and applied to the 
external parts. In special cases, which require an antiseptic plan 
of treatment, Dr. Miller makes use of a solution of thymol, 1 
part to 500 parts of water, or, better, three grains of thymol to 
an ounce of eau de cologne. This mixture, which has a pleas- 
ant and rather refreshing odor, is simply sprinkled over the nap- 
kins before they are used. In severe cases, with a putrid odor, 
a solution of permanganate of potassa, injected with Higginson's 
syringe, provided with a vaginal portion, is made use of; the 
injection of the fluid is continued till it returns unaltered in color. 
In all cases where the discharge is excessive, tincture of arnica 
is employed ; the tincture is used in the proportion of one tea- 

29 



450 COMPLICATIONS OF PARTURITION. 

spoonful to a cupful of water ; it acts as a mild astringent and 
disinfectant. 



PEOF. FORDYCE BARKER, M. D., NEW YORK. 

This author has an exalted opinion of veratrum viride in this 
disease. He however recommends small doses, and the effects to 
be carefully watched. If the remedy produces symptoms of de- 
pression, these symptoms have been readily dissipated by brandy, 
whiskey, or carbonate of ammonium. The veratrum viride 
should not be discontinued too early, as its premature withdrawal 
may be attended with renewal of the symptoms. He usually 
commences by giving five drops every hour, and gradually in- 
creasing the dose, if there be not a perceptible impression upon 
the pulse after giving two or three doses. After the pulse is 
reduced, it is thus maintained by administering two, three or 
four drops every second hour. 

It is also very important in this disease to allay pain, quiet 
nervous irritation, and secure sleep. These ends are best secured 
by opiates. He prefers Magendie's solution of morphia by the 
mouth, if the stomach is not irritable, but hypodermically, if 
there be nausea and vomiting. 

The next indication is to reduce fever. Quinine, mineral 
acids, cold sponging, alcohol, and appropriate nutrition, are 
the antipyretics upon which the medical profession now relies. 
Of the mineral acids, our author prefers phosphoric acid. He 
believes that it allays nervous irritability and that it acts specifi- 
cally as a tonic. He adds a teaspoonful of the dilute acid to a 
tumblerful of water, flavored with the syrup of orange peel. 
If the patient be disinclined to drink, he has sometimes substi- 
tuted ten to fifteen drops of dilute sulphuric acid every two or 
three hours. The treatment of pysemia must be governed to a 
great extent by the therapeutical indications of its associated 
diseases. Prof. B. regards quinine and alcohol as the two great 
remedies in the constitutional treatment of this disease. He 
prescribes 10 to 15 grains of quinine in the morning, and 



PUEKPEKAL FEVER. 451 

from 15 to 20 at night. If from idiosyncrasy there is 
an intolerance of this agent, he combines it with from 10 to 
15 grains of the bromide of potassium. This counteracts 
the unpleasant cerebral symptoms which sometimes occur. He 
has never seen quinine produce paralysis of the motor power of 
the heart. He thinks a free use of stimulants obviates this 
danger. These he pushes to a degree of tolerance. To procure 
rest he advises an opiate at bed-time. Food the most nourish- 
ing and the most easily digested should be urged upon the 
patient, and skill should be used to make it tempting and palata- 
ble. If the urine become scanty, bloody and albuminous, he 
orders dry cups over the kidneys, the free use of diluent drinks, 
and the tincture of the chloride of iron. The latter is very 
useful in conjunction with the chlorate of potassium when there 
are very profuse discharges of pus from external abscesses. He 
esteems the following combination : 

321. R. Tinct. ferri chloridi, f.|ss. 

A quae purse, f.Sj ijss. 

Potassii chloratis, sj ss. 

Syr. anrant cort., 

Glycerini puri, aa f . ^ i j . M. 

SiG. — TablespoOnful in a wineglassful of sugar and water four times a day. 

PEOF. W. S. PLAYFAIR, M. D., LONDON, 

Eegards the indications : to discover, if possible, the poison, in 
the hope of arresting further septic absorption ; to keep the pa- 
tient alive until the effect of the poison has worn off; and to treat 
any local complications that may arise. Antiseptic injections 
must be employed at least twice a day. He employs Higginson's 
syringe, with a long vaginal pipe attached. He prefers the alter- 
nate use of Condy's fluid largely diluted, and the tincture of 
iodine. The washing should be thorough, and by the physician 
himself. Food and stimulants to keep up the powers. Not 
more than one or two hours to elapse without nutriment of some 
kind. In moderate cases a tablespoonful of brandy or whiskey 
every four hours ; but when the pulse is rapid and thready, there 



452 COMPLICATIONS OF PARTURITION. 

is low delirium, tympanites or sweating, indicating great exhaus- 
tion, give them in larger quantities and at shorter intervals. In 
severe eases, 8 to 12 ounces, or even more, may be given in 
twenty-four hours, with benefit. Never bleed. 

Give medicines to lessen the force of the circulation, without 
exhausting, and to diminish the temperature. Tine, of aconite 
is most valuable. Give a single drop every half-hour, increasing 
the interval according to the effect. Generally, after four or 
five doses, the pulse falls, and then a few doses every two hours 
will suffice. Watch it, and stop if the pulse becomes too weak, 
or intermits. 

To reduce the temperature, give quinine, 10 to 20 grains, 
morning and evening. The head, and other unpleasant symp- 
toms, may be lessened by the addition of 10 to 15 minims of 
hydrobromic acid to each dose. Salicylic acid, ten to twenty 
grains, or the salicylate of soda in the same dose, is a valuable anti- 
pyretic. It requires to be watched. 

Warburg's tincture, the basis of which is quinine, has a pow- 
erful antipyretic effect. 

Cold may be applied in suitable cases. The ice- cap is best ; 
it comforts, relieves the throbbing headache, and the tempera- 
ture usually falls. When the temperature reaches 105°, cold to 
the body may be used, but only as a temporary expedient. 

Where there is much tympanites, turpentine, 15 to 20 
minims, may be given in mucilage. It acts as a strong nervine 
stimulant. 

Purgatives are doubtful, and often exhausting. 

M. D., LONDON. 

Quiet the system by opiates in the early stages, moderately 
excite the bowels by a saline, stimulate the skin by small doses 
of carbonate of ammonia or other stimulating diaphoretics. Local 
applications, poultices to the abdomen to keep the part warm 
and moist, will be of service, and opium may be added to 
these. 



PUERPERAL FEVER. • 453 

When the reactive phenomena of inflammation are well marked, 
leeches may be applied over the abdomen, from six to twelve, as 
may be demanded. 

Venesection, when needed, must be pleno rivo, thus producing 
the effect at once, and with less loss. Next, nauseating doses of 
tartar emetic to lower the force of the heart's action ; and if the 
pulse again becomes hard and full, repeat the bleeding till 
the disease is subdued. Calomel and opium freely, in order that 
the system may be brought quickly under the mercurial. Mer- 
curial frictions may be used. Turpentine has been successfully 
given in half-ounce doses, two or three times a day, especially 
in tympauites. 

The uterus should be well disinfected by warm water and 
carbolic acid, or Condy's fluid. If there be much pain, give 
Dover's powder frequently, and keep up the strength. 

His own plan is to support, by a moderate use of stimulants, 
a hot, dry skin being a contra-indication ; warm emollients to 
the vagina and to the abdomen ; cleanliness in the atmosphere, 
the clothes and the uterus. The diffusible stimulants, opiates, 
salines, diaphoretics, and vegetable tonics, when the acute symp- 
toms are gone, are the drugs to be preferred. With a high tem- 
perature, pulse quick, hard and full, skin hot and dry, nothing 
can compare with aconite, one drop every hour. 

WALTER IZARD, M. D., LIBERTY, VA., 

In the Va. Med. Monthly, Aug., 1878, regards the cause to be 
the retention and absorption of excrementitious and morbific 
matter. Hence he strikes at the root by employing, not intra- 
vaginal washes, but intra-uterine. He employ a double catheter 
similar to that in common use for washing out the bladder, only 
with a larger and more gradual curve, and a slight prolongation 
of two tubular orifices through which the injected fluid makes its 
entrance and exit ; the exit tube should be several sizes larger 
than the other. It may be made of gutta percha or silver ; two 
pieces of rubber tubing, two and a half to three feet long, should 



454 COMPLICATIONS OF PARTURITION. 

then be fitted to the tubular orifices; to that of entrance, a large 
glass funnel should be attached. 

Everything being prepared, and the patient occupying the 
dorsal decubitus, with the lower extremities flexed, and the body 
having been placed near the edge of the bed by assistants, the 
left index-finger, well oiled, should be placed in contact with the 
external os uteri; then the catheter, passed along this finger as 
a guide, should be passed to the fundus uteri — meeting in this 
condition no resistance at the internal os. Then the fluid having 
been poured into the funnel, it should be raised to the 
height of two feet above the bed, and the fluid allowed to flow 
into the uterus, the only force used being hydrostatic pressure. 
The fluid will be found to return almost immediately through 
the waste tube, so changed in appearance as to leave no doubt as 
to whether it has come in contact with the internal uterine walls 
or not. This funnel arrangement is the one calculated to accom- 
plish the desired end with the least possible amount of injurious 
force. By the Davidson's or any other pump syringe, the fluid 
is thrown in with such force as almost to render its escape 
through the fallopian tubes a certainty. 

The washing out of the uterine cavity should cause no pain, 
although slight uneasiness is sometimes complained of by patients 
during the introduction of the instrument. The fluids used for 
washing out the uterine cavity have been several — preferably 
potassse permanganate (grs. vijss. to Oj. of tepid water,) or car- 
bolic acid(3j. to Oj. of water) and a weak solution of salicy- 
late of soda in glycerine and water. 

JOSEPH HOLT, M. D., OF NEW ORLEANS. 

In reviewing the subject this writer says (New Orleans Medi- 
cal Journal, Sept., 1876,) that the physician's first duty is to 
guard every obstetric patient against septic contamination from 
without, by refraining from attending such cases if we have rea- 
son to believe that our hands or clothing are infected ; by the 



PUERPERAL FEVEE. 455 

liberal use of disinfectants about the apartment or premises, and 
even removing the patient if we suspect the unhealthiness of the 
locality. 

We are to guard against auto-infection by cleanliness, by the 
free use of vaginal injections when there is even the slightest 
putridity of the lochia, by the immediate removal of any rem- 
nant of decomposing placenta or coagula, by the avoidance of 
anything likely to check the lochial discharge, as cold and 
dampness, and when it is checked, inviting it again by the re- 
peated warm douche. As a disinfecting wash, he earnestly 
recommends the formula of Dr. I. L. Crawcour, of New Or- 
leans : 

322. R. Acidi carbolici^ jfj. 

Tincturae iodinii composite, f. % ss. 

Glycerinse, f.^ijss. M. 

Sig. — A tablespoonful to be stirred into a quart of tepid water, and in- 
jected high up in the vagina two or three times daily, as the case may re- 
quire. 

If infection has already occurred, we are to look to antiseptic 
remedies as offering the most reasonable hope of success. If 
puerperal fever is septicaemia, it is irrational to expect a positive 
controlling influence from opium or calomel, purgatives, emetics, 
venesection, cardiac sedatives, or any other remedy not having 
the quality of directly disinfecting the blood. 

There is no doubt but that some of these drugs and expedients 
are extremely useful in the treatment of this disease, but as a 
mainstay, experience has taught that none of them are to be 
relied upon. He has administered, with an apparent speedy 
amelioration of symptoms, the following formula : 

323. R • Acidi carbolici, gtt. xr. 

Sodii sulpho-carbolatis, % ss. 

Glycerinse, f. 5 j. 

Aquse, f.'^ v. M. 
SiG .— Tablespoonful every three hours 



456 COMPLICATIONS OF PARTURITION. 

The old remedies, approved by experience, are called for when 
specially indicated ; as in many cases keeping the bowels freely 
open by mercurial purgatives, the pill of calomel and compound 
extract of colocynth, subduing excessive heart-action with vera- 
trum viride, blistering when the inflammation localizes itself, 
and attending to the state of the lochial discharge. 

In cases where the local inflammation is attended with excru- 
ciating pain (of such common occurrence,) he has been able to 
control it perfectly by applying over the suffering part a fly- 
blister, removing the cuticle, and then laying on a plaster com- 
posed as follows : 

324. R . Ex. belladonna?. 

Ex. opii, aa gj. 

Adipis, % j. M. 

For a plaster. 

The effect of this plaster is so tranquilizing as to do away with 
the necessity of narcotics given internally. The physician must 
carefully watch its effect, and remove it for a while if much nar- 
cotism is induced, protecting the blistered surface in the mean- 
time with an emollient poultice. The strength of it may be in- 
creased or diminished according to the effect, and it may be 
continued as long as there is abdominal tenderness. 

PROF. CARL RICHTER, M. D., OF BERLIN. 

The treatment of puerperal disease pursued by this writer 
(Zeitschrift fur Gyn., 1877,) may be briefly stated, as follows: 
As soon as the lochia became offensive or arrested, or offensive 
placental debris or coagula were discharged, or the temperature 
or pulse rose, or any inflammatory reaction in the genital tract 
appeared, or the uterine regions and surroundings became sensi- 
tive, or the broad ligaments appeared swollen — at once the 
uterine cavity and vagina were thoroughly washed out, first with 
a three per cent., then with a two per cent, carbolic solution, two 
or three times a day ; the permanent ice-bladder was applied, 



PUERPERAL FEVER. 457 

preceded, if indicated, by leeches ; and, according to the severity 
of the symptoms, first salicylate of soda in doses of gr. xv.-xxx. 
several times a day. The ice was continued so long as sensitive- 
ness remained; the irrigations and soda salicylic, until pulse 
and temperature were reduced to the normal. 

It should be mentioned that a combination of sulphate of 
quiniae (gr. viij.,) with soda salicylate (gr. xv.-xxx.,) could be 
relied upon with tolerable certainty, although but temporarily, 
to reduce the high temperature, without causing salicylic in- 
toxication; a ten per cent, solution of carbolic acid was very 
useful as a local application to wounds of the parts. 

W. H. PARISH, M. D., PHILADELPHIA, 

In a paper read before the Philadelphia Co. Med. Soc, being a 
clinical study of the cases at the Philadelphia Hospital, con- 
cludes as follows : 

Puerperal fever and puerperal septicaemia are dependent upon 
one and the same poison, and this poison originates in a great 
variety of forms of decomposing organic material. The source 
of the poison may be within the woman herself, or it may have 
its origin in sources external to her. 

Puerperal fever or puerperal septicaemia may be conveyed from 
one puerperal patient to another. 

If a lying-in patient is suffering with traumatic inflammation, 
she is thereby rendered more liable to internal infection. 

The poison develops with great rapidity in a lying-in patient 
suffering with traumatic inflammation, and from her it may be 
transferred to other lying-in patients, and in them it may pro- 
duce septicaemia or puerperal fever, though the original patient 
may herself have escaped infection. 

In a patient suffering with auto-genetic infection, the symp- 
toms vary greatly, according to the absence or presence and 
degree of traumatism, and according to the special mode of the 
internal infection. 

The symptoms in patients suffering from external infection are 



458 COMPLICATIONS OF PARTURITIOX. 

more uniform in their manifestations, as are also the pelvic and 
abdominal lesions. 

The treatment of cases of internal infection must vary greatly 
for the same reasons that the symptoms vary. 

In cases of external infection, the treatment is more uniform, 
and should consist, as a rule, of local abstraction of blood by 
leeches, (f. I xvi.-xx.,) of warm, moist applications, of warm, dis- 
infecting vaginal or intra-uterine injections, of quinia in full 
doses, of morphia as a calmative, of a mild diuretic, of stimulants 
according to depression, of moderate constipation after an enema, 
and of liquid and highly nutritious diet. 

The prophylaxis is of, however, paramount importance, and 
should consist of measures that will prevent the formation of 
septic material within the woman, and that will prevent the con- 
veyance of septic material to her person from external sources. 

RESUME OF KEMEDIES. 

Acetum. As a germ -destroyer and disinfectant, Dr. Alexan- 
der Siicpsox, of Edinburgh, calls attention to com- 
mon vinegar, which on many occasions he has found 
extremely efficacious. [Trans. Internal. Med. Congress, 
1876.) 

Aconitum. Phillips is very positive as to the good effects of 
aconite in drop doses every hour or two, day and night. 
If employed immediately after signs occur, it will be 
most beneficial. 

Alcohol in strong solution has been used by French practitioners, 
and is strongly advocated by Dr. J. T. Whittaker, 
Cincinnati, (Obstetric Gazette, October, 1880,) who 
says : " For the reason that alcohol in large doses is 
antiseptic, is antipyretic, and is nutritive, it is eminently 
the food for fever, and pre-eminently for puerperal 
fever." 

Arnica is used by Dr. Miller. 

Calcii Chloridum in weak solution is available. 

Carbolicum Acidum is the most widely used of the antiseptic 
agents. (See above.) 



PUERPERAL FEVER.. 459 

Chloral Hydras. Dr. J. A. Larrabee, of Louisville, has found 
a solution of chloral of mild strength, gr. x.-f. ?j., 
much more efficacious in checking an epidemic of puer- 
peral fever than carbolic acid or anything else. (Half- 
Yearly Compendium, July, 1878.) He states that in 
all labors there is an odor to the lochia, plainly dis- 
cernible at the end of the first twenty-four hours. If 
this condition remains uncorrected, and the nurse neg- 
lects to attend to her duties, there is great danger of 
septic-poisoning. A solution of chloral of mild strength, 
in water, and by means of the douche or fountain syr- 
inge, removes at once not only the odor, but destroys 
the noxious influence of such poison. Carbolic acid, 
although it has been much lauded, is, in his judgment, 
entirely unreliable, and merely substitutes its own odor 
for that of the disease. 

Digitalis has been employed by Dr. Winckel as an abortive of 
puerperal fever. It reduces temperature, and produces 
rest and sleep. (Ranking's Abstract, vol. XXXVI.) 
He uses the following formula for hypodermic injec- 
tion : 



325. R . Digitalini .001 gramme. 

Alcoholis, 
Aquae, aa ad 3. 

In true septic fever it is useless, and Amann warns 
against the large doses administered by some prac- 
titioners. 

Collodion. For the prevention of puerperal diseases, Benoist at- 
tributes great efficiency to the application of collodion 
over the abdomen to overcome inflammatory affections. 

Eucalyptus. According to Hertz the tincture of eucalyptus is 
next in efficiency to quinine, and should always be 
tried when the latter fails. The effect is prompt, and 
there are no unpleasant after-effects. Two or three tea- 
spoonfuls of a tincture of the fresh leaves is the dose 
he recommends. Osterloh, of Dresden, has also 
testified to the value of this drug, especially where 
febrile symptoms appear without marked local disturb- 
ance. 



460 COMPLICATIONS OF PARTURITION. 

Ergota is considered by F. Benoist to be an efficient agent 
against putrid infection. 

Ferri Chloridi Tinetura. Dr. Charles Bell, in describing some 
cases of puerperal fever in the Edinburg Medical 
Journal, July, 1880, says of its treatment: "I have 
found no remedy so effectual in purifying the system 
as the Edinburgh preparation of the tincture of the 
muriate of iron when given regularly in full doses 
frequently repeated. The great error in the employ- 
ment of this medicine is the timidity shown in giving 
it in sufficient doses ; in consequence its good effects 
have been questioned in the diseases of a zymotic char- 
acter, such as erysipelas, diphtheria, and scarlet fever. 
It has remarkable effect in moderating the pulse and 
diminishing the secretion of pus. At the same time, 
I think it right to warn the practitioner against trusting 
to the new preparation of iron called the tinetura ferri 
perchloridi, which differs from the tincture ferri muri- 
atis in its formation, its medicinal effects, and in its 
analysis." The dose he gives is 30 drops every two 
hours, well diluted. 

Ferri Suhsulphas is an antiseptic agent of value, as well as a 
haemostatic. Dr. A. P. C. Wilson, of Baltimore, 
recommends that it be combined with glycerine when 
used in the uterine cavity. 

Hydrargyrum. The mercurial treatment still has defenders in 
England, (see p. 453,) but is nearly obsolete elsewhere. 
Calomel in small doses is given until salivation is pro- 
duced. 

Iodinium. Dr. E. J. Tilt believes that tincture of iodine is the 
best disinfectant for uterine injections. He uses as an 
injection after labor, four drachms of the tincture in 
half a pint of tepid water. He speaks very highly of 
the results of the practice of Dr. Dupierris, of Cuba, 
who had great success in preventing and curing puer- 
peral fever by injecting into the womb, immediately 
after removing the placenta, the following : 

326. R . Tincturse iodinii, f. g iv. 

Potassii iodidi, gr. x. 

Aquae destillatse, f-ilj* M. 

For one intra-uterine injection. 



PUERPERAL FEVER. 461 

Opium and Morphia. Enormous doses of these preparations 
can be taken with advantage in puerperal fever. Dr. 
J. P. White, of Buffalo, says he has given as much 
as one grain of morphia every hour for forty-eight 
consecutive hours, with success. Dr. E. H. Tren- 
holme, of Montreal, gives from one grain to a grain 
and a third hourly, and has never lost a case. [Trans. 
Internat. Med. Congress, 1876.) When opium and its 
derivatives cause vomiting, they are contra-indicated 
or must be administered in combinations which will 
avoid this. Amann says that the following will not 
be followed by vomiting even in cases predisposed 
to it: 

327. K . Atropiae, 1 part. 

Morphiae sulphatis, 15 parts. 

Aquae destill., q. s. M. 

For hypodermic injection. 

Potassii Permanganas in weak solution answers very well as an 
antiseptic wash. One objection to it is, that it stains 
the bedding, etc. Where soreness and tenderness of 
the vagina after labor are complained of, Dr. P. J. 
Murphy, of the Columbus ■ Hospital for Women, 
Washington, uses : 

328. &. Potassii perm anganatis, 9j. 

Potassii chloratis, % iv. 

Aquae, O ij. M. 

A teaspoonful to be added to a quart of warm water, and used as 
a vaginal injection night and morning. Dr. Bartholow states 
that internally" it has been given with advantage, gr. J-j., in 
water, three times a day. 

Quinice Murias. This salt is decidedly preferred by Amann 
(Klinik der Wochenbettkrankheiten,) on account of its 
being so much better borne by the stomach than the 
sulphate. He orders the quinine in one or two large 
doses, from gr. viij.-xxiv., at a dose, and this twice 
daily for one or two days, and then allows two or three 
days to intervene. The patient should be informed 
that she will experience quininism, but that the state 
is temporary and harmless. 

Quinice Sulphas, especially in the form of " Warburg's tincture," 



462 COMPLICATIONS OF PARTURITION. 

lias lately been asserted to be a very valuable remedy 
in puerperal septicaemia. Cases are given by Dr. A. 
Baird, Edinburgh. (Med., Jour., August, 1879.) 
Bartholow speaks of the undoubted good effects of 
quinia in doses of gr. v.-xx., every four hours. Dr. 
R. Park (Glasgow Med. Jour., October, 1880,) has 
given as much as 3j. at once, with no other effect than 
intensifying the sufferings of the patient. 

Salicin, internally, has been used by Duncan and others, and 
is spoken of as a reliable antipyretic. 

Salieylicum Acidum has been used both locally and internally. 

Sodii Benzoas has been introduced comparatively recently by 
Prof. Klebs, of Prague. It is said to be useful in every 
kind of septic injection. The dose is 3 ij.-iv. in solu- 
tion, repeated as needed. A few cases have been re- 
ported in which its administration seemed to do good, 
but they have not been sufficiently numerous to be 
decisive as to its merits. 

Sodii Salicylas, as more agreeable than the acid, should be pre- 
ferred for internal use. 

Sulphurosum Acidum, for injection and irrigation, has been 
advocated. 

Terebinthinw Oleum is said, by various writers, to have decided 
clinical experience in its favor. It has been found of 
advantage applied both externally and internally. Dr. 
Copeman gave f. 3j. thrice daily. (Med. Times and 
Gazette, 1872.) Hogg-, of Scotland, as much as f. 3iij. 
at a dose, in whiskey punch, in desperate cases. It 
may also be thrown up the rectum, or applied to the 
surface of the abdomen. For the latter purpose tur- 
pentine-flannel is available. A piece of flannel is taken 
large enough to cover the whole abdomen ; it is dipped 
in hot water and wrung out dry, then sprinkled with 
turpentine and laid, while as hot as possible, on the 
skin, and covered with dry cloths and wash-leather. 
This is repeated until the skin becomes decidedly red. 

Thymol has been employed as an antiseptic by Dr. Miller. 

Veratrum Viride has its defenders as a valuable means to control 
arterial action. But the present tendency is to distrust 
this drug. 



PUEEPEEAL FEVEE. 463 

GENEEAL MEASUEES. 

Blisters are often of great service, especially in the later days of 
the fever, when Duncan recommends "a large fly- 
blister of the old-fashioned sort, so as to produce great 
irritation and a copious effusion of serum." 

Leeches. Prof. Duncan observes that in milder cases where 
there is parametritis or perimetritis as many as a dozen 
leeches, applied above the groins, generally cause 
marked relief of pain and some improvement of the 
general condition. 

Intra- Uterine Injections. These have been fully discussed on 
previous pages. There is no doubt they are most ben- 
eficial in many instances of this disease. Weak car- 
bolic acid solutions appear to be the best. Salicylic 
acid produces a roughness of the mucous membrane, 
and permanganate of potash stains the linen, In in- 
troducing the catheter great care should be taken not 
to wound the inflamed lining of the uterine cavity. It 
is well to close the genital fissure for a few seconds, so 
as to retain the injection longer. 

Cold. An important measure is the application of cold. It may 
be employed as lukewarm, cool or cold baths, ice-bags, 
or cloths wet with cold water. These are to be chosen 
with reference to the height of the fever and the 
strength of the patient. In light cases cold cloths or 
ice-bags to the head may be sufficient ; in severer ones, 
the cloths should be applied to the abdomen or the 
whole body. The latter, however, is not convenient in 
parturients. Cool baths are very efficient, but by no 
means easy to carry out in private practice. 

Purgatives. Seyfeet, of Prague, was so convinced of the good 
effects of purgatives in these fevers that he adminis- 
tered large doses of cathartic waters in all cases, and 
laid down the maxim, "Puerperal fevers are only 
curable by a diarrhoea," either spontaneous or arti- 
ficially produced. Prof. Amann (Klinik der Wochen- 
bettkrankheiten, § 148,) who quotes this opinion with 
some approval, prefers calomel to all other purgatives. 
He gives gr. v. every two hours until the bowels act 
freely ; or in light cases, castor oil in coffee. These 



464 COMPLICATIONS OF PARTURITION. 

are the only two purgatives he considers proper in 
such cases. 
Venesection is less used than formerly. As the disease is one of 
an asthenic character, the cases in which loss of blood 
is desirable must be very rare and exceptional in 
number. 



PUERPERAL THROMBOSIS AND EMBOLISM. 465 

PUERPERAL THROMBOSIS AND EMBOLISM. 

PROF. W. S. SPLAYFAIR, M. D., LONDON". 

When there are evidences of pulmonary obstructions generally, 
the fatal results follow so speedily that no time is given to do 
anything. Keep the patient alive by stimulants, brandy, ether, 
ammonia. Possibly leeches or dry cups to the chest might aid 
in relieving the circulation. Enjoin the most absolute and com- 
plete repose, with the hope that the vital functions may be con- 
tinued until the coagulum is absorbed or lessened, so as to permit 
the passage of the blood. Death often follows the most trivial 
exertion, such as rising out of bed. Feed the patient with 
abundant fluid food, milk, strong soups, and the like. 

Richardson suggested ammonia. He has since advised 
liquor ammonia in large doses, 20 minims every hour, in the 
hope of causing solution of the deposited fibrine, and says he has 
seen good results of it. Others urge the use of alkalies to favor 
absorption. The best that can be said of them is, that they are 
not likely to do much harm. 

Where there is evidence of obstruction in a limb or other 
point, nothing can be done. Rest absolute, generous diet, and 
sedatives for pain, is all. In case of gangrene of an extremity, 
amputation above the line of demarkation may save the life of 
the patient. 

THKOMBUS. 

PROF. F. WINCKEL, M. D., DRESDEN. 

If the vagina be the location, plug with cotton-wool or with a 
colpeurynter filled with ice-water. Cold to the tumor, if in the 
labia, and ice, digitalis and opium internally, the latter to allay 
excitement and pain. When it ceases to enlarge, use absorbents. 
Do not open, unless a special indication to that effect exists. 

30 



466 COMPLICATIONS OF PARTURITION. 

Employ ice compresses, cloths soaked in warm lead-water and 
opium, 4 drachms tinctura opii to one pound of lead-water, infu- 
sion of chamomile flowers, arnica, etc. 

If the tumor does not decrease, the pain is intense, and the 
skin gets darker, open, turn out the clots, and if the bleeding 
continues, fill the cavity with charpie soaked in solution of 
tannin, or, better, a three per cent, solution of carbolate of soda ; 
lay a compress over it, and secure with a T bandage. It is best 
to wait, if possible, until the hemorrhage has ceased, before 
opening the tumor. General indications will be to support the 
system, and give quinine and acids. 

Vaginal thrombus usually arises immediately during or after 
child-birth, and is formed in the loose tissue between 
the vagina and rectum, whence, however, it sometimes ex- 
tends to the gluteal regions, and even to the thighs and psoas 
muscles. The treatment as recommended by Dr. Kubker 
(Wiener Medicin. Wochenschrift, Xo. 52, 1878,) consists in the 
prompt application of cold, as ice and ice-water, and compres- 
sion. As soon as the thrombus ceases to extend, poultices are 
indicated. 

PROF. FORDYCE BARKER, M. D., NEW YORK. 

If the thrombal tumor be not so large as to cause great pain 
by its pressure on the adjacent tissues, or to interfere materially 
with the delivery, or if laceration and escape of blood almost 
immediately follow the development of the tumor, apply the 
forceps and deliver at once. Arrest the flow of blood which 
usually occurs at the moment of the delivery of the head, with 
compresses of cotton batting saturated with a solution of the sub- 
sulphate of iron. As soon as this hemorrhage is controlled, 
deliver the placenta. He opposes the use of the tampon, on the 
ground that it retains the lochial discharge, and exposes the 
patient to septic poisoning. 

To the laceration he applies a lotion of carbolic acid and 



PUERPERAL THROMBOSIS AND EMBOLISM. 467 

glycerine, not only as an antiseptic, but as a means of protecting 
the part from excoriation by the irritating discharges of the 
urine and the lochia. Avoid disturbing the coagulum formed by 
the subsulphate of iron, so as to avoid secondary hemorrhage. 
As a precaution against this accident, the bladder should be 
evacuated for several days by a catheter. 

When the tumor has attained such a size as to offer a mechani- 
cal obstacle to delivery, incise at once, remove all clots that 
have been formed, and then deliver by the forceps. The longer 
the incision is postponed, the greater will be the amount of ex- 
travasation, the greater the distention of the parts, and the more 
extensive the laceration of the areolar tissue. 

If the laceration does not appear until after delivery, incision 
should not be made so long as the tumor is increasing in size. 
He advises that the physician should wait until after the coagu- 
lum is formed, which arrests the hemorrhage by pressure on the 
lacerated vessels. 

DR. JOSEPH AMANN, OF MUNICH. 

Hcematoma. Little or nothing can be done to guard against 
a haamatoma. As soon as one appears, it is the duty of the 
physician to limit it as much as pcssible. This is best done by 
introducing a coutchouc tampon filled with ice ; or by filling 
the vagina with carbolated wadding, or carbolized sponge 
(sponge soaked in a two per cent, solution of carbolic acid.) By 
such a measure a thrombosis of the bleeding vessels is produced, 
the hemorrhage checked, and increase of the hematoma limited. 
Large tampons are required ; if properly applied, a tumor as 
large as the fist can be reduced, and safely conducted to absorp- 
tion. 

In more serious cases inflammation and gangrene may super- 
vene ; the skin becomes discolored and tense, and threatens to 
break. In such cases the indication is to make an incision at 
the most dependent part of the tumor, empty its contents, and 



468 COMPLICATIONS OF PARTURITION. 

wash with injection, of a dilute solution of chloride of iron 
(1 to 200.) When the tumor is very large, with neither inflam- 
mation nor absorption goiug on, it is best to wait four to five 
days, when an incision may be made with less danger of hem- 
orrhage following. 



PUERPERAL SHOCK. 46 9 

PUERPERAL SHOCK. 

PROF. WM. LEISHMAN, M. D., GLASGOW. 

Shock to the nervous system by a tedious or severe labor may 
prove fatal, without hemorrhage or organic injury. As Travers 
'observes, pain of itself is destructive. This author believes it 
must be the pain of the second stage. The treatment is the 
union of an anodyne with stimulants ; wine and brandy freely, 
till reaction is obtained, and then substituted by chicken broth. 
Meantime, give 

329. R. Mist, camphorse, f-o v J« 

Ammon. carb., 3 ij. 

Tr. opii, gtt. Lt. M. 

Dose, a tablespoonful every one, two, or three hours. With this, she 
must be perfectly quiet, ♦the room darkened, and the patient allowed to sleep 
as long as she can. 

It is with a view to avoid the shock, the exhaustion of the 
second stage of labor, that the editor would urge the use of 
chloral, until the delivery can be accomplished by the employ- 
ment of the forceps. The best treatment will be to prevent 
shock by avoiding its causes. 

It would appear that chloral, even while producing a calm, 
refreshing sleep, does not by any means check the progress of 
labor when this has commenced. For it is invariably found 
that dilatation has continued, and generally so readily is this 
accomplished, that a speedy delivery often follows its use. The 
editor regards this remedy as producing results similar to those 
of anaesthetics in surgery, and therefore similarly indicated. 
Again, while it relieves the pains of travail, it thus greatly con- 
tributes to a safe and speedy convalescence. It prevents the ter- 
rible exhaustion and shock to the system too often seen to follow 
an unaided labor.* 

* On the prevention of shock by the early use of the forceps, see also that 
subject in " Hints in the Obstetric Procedure." 



470 



COMPLICATIONS OF PARTURITION. 



PELVIC CELLULITIS AND PERITONITIS (PUERPERAL 
PHLEBITIS AND METRITIS.) 

T. G. THOMAS, M. D., NEW" YORK, 

Has tabulated the points of differential diagnosis between pelvic 
cellulitis and peritonitis as follows : 



Cellulitis. 

1. Tumor easily reached; gen- 
erally felt in one broad liga- 
ment ; may be felt above the 
pelvic brim. 

2. Marked tendency to suppu- 
ration. 

3. Abdominal tenderness in 
one iliac fossa. 

4. Tumefaction laterally in the 
pelvis. 

5. Tendency to monthly re- 
lapse not marked. 

6. Pain severe and steady. 

7. Facies not much altered. 

8. Nausea and vomiting not 
excessive. 

9. Not accompanied by tym- 
panites. 

10. Uterus fixed to a limited 
extent. 

11. Not necessarily displaced. 

12. Cause. Parturition, abor- 
tions, operations on the pel- 
vic viscera. 



Peritonitis. 

Board-like feel to the vaginal 
roof. Tumor very high, only 
felt in the vaginal cul de sac ; 
does not extend above the 
superior strait. 

Suppuration rare. 

Abdominal tenderness excessive 
above the brim. 

Tumefaction near or upon the 
median line. 

Tendency to monthly relapse 
very marked. 

Pain excessive, often paroxys- 
mal. 

Very anxious. 

Nausea and vomiting often ex- 
cessive. 

Always accompanied by tympa- 
nites. 

Uterus immovable on all sides. 

Always displaced. 

Diseases of the ovaries, gonor- 
rhoea, exposure during men- 
struation, fluid in the peri- 
toneum. 



PELVIC CELLULITIS AND PERITONITIS. 471 

PROF. WM. GOODELL, M. D., PHILADELPHIA, 

In Philadelphia Medical Times, 1880, gives the following 
advice as to treatment : 

The disease having been recognized, administer at once a full 
hypodermic dose of morphia, and from 10 to 20 grains of 
quinia by the mouth. These measures, taken promptly, will 
often stop the disease at once. 

Failing to abort the attack, we must paint the abdomen with 
iodine and put on a poultice, covering it with oiled silk, or 
greased brown paper ; it will then remain soft for twenty-four 
hours. The patient must have large doses of quinia. If the 
temperature be high she should have 10 grains at a time, and 
from 30 to 40 grains in the course of the day. Large doses 
of morphia must also be given. If the woman be plethoric, the 
morphia may be given by the mouth, with neutral mixture and 
wine of ipecacuanha, or in some other fever mixture. In some 
cases tonics are demanded. If the sickness last for more than a 
week, and the local tenderness increase, put on a blister promptly. 

Later, muriate of ammonia is an excellent remedy in this dis- 
ease ; so, too, is aconite. Dr. Goodell usually prescribes the 
following : 

330. R. Mist, glycyrrhizse comp., £,^ v j- 

Ammonise muriatis, gij. 

Hvdrarg. chloridi corrosivi, gr. j. 

Tinct. aconiti radicis, gtt. xxiv. M. 
A tablespoonful in water every six hours 

As concerns routine treatment, the patient should take plenty 
of milk, whiskey, beef- tea, and large doses daily of dialyzed iron. 

PROF. W. S. PLAYFAIR, M. D., LONDON. 

The important points are relief of pain and absolute rest. If 
seen at an early stage, blood taken locally by leeches to the groin 
or to the hemorrhoidal veins may give relief. Leeches to the 



472 COMPLICATIONS OF PARTURITION. 

uterus are likely to cause harm by the irritation of passing the 
speculum. Opiates in large doses, or by suppositories, or subcu- 
taneously, are the best when the pain is at all severe. When 
paroxysmal, use suppositories immediately the pain threatens. 
When there is much pyrexia, give large doses of quinine. Keep 
the bowels free ; nothing answers so well as castor oil, one-half 
a teaspoonful every morning. Warmth and moisture to the 
abdomen give great relief in the form of linseed-meal poultices ; 
or if these are too heavy, use spongeo-piline soaked in boiling 
water. Poultices may be sprinkled with laudanum or bella- 
donna liniment. Absolute rest in the recumbent position must 
be enforced for some time after the symptoms abate. Then ab- 
sorption may be favored by the long-continued use daily of tinc- 
ture of iodine until the skin peels, or by frequently-repeated 
blisters. This is better than keeping an open sore by irritants. 
When an abscess has formed and points in the groin, make a 
free incision, and employ antiseptics. Wait till the pus is near 
the surface. In these operations, the aspirator is a valuable 
instrument. 

Diet should be abundant, simple and nutritious. Make up for 
the drain caused by suppuration. Tonics, iron, quinine, and cod- 
liver oil, will be useful. 

DR. JAMES R. CHADWICK, OF BOSTON. 

In conditions that follow inflammation of the pelvic organs 
and of the pelvic peritoneum or cellular tissue, characterized by 
painful defecation, backache, pain, burning sensation, etc., this 
practitioner has used with great relief the hot rectal douche. 
(Trans. Amer. Gyn. Soc, 1880.) The method of administering 
it with a view to obtaining its utmost benefits, aims at securing 
the passage of the water in large volume to as high a point as 
possible in the alimentary tract, and its retention for as long a 
period as possible. Water is taken at as high a temperature as 
can be borne by the hand ; the patient is placed upon her side, 
preferably the right, in bed ; a fountain syringe, holding two 



PELVIC CELLULITIS AND PERITONITIS. 473 

quarts, is employed, suspended quite low, so that the flow of 
water may be slow ; as soon as the patient has a sensation of a 
desire to defecate, or the rectum is felt by the finger in the vagina 
to be distended, the current of water is arrested for a few min- 
utes, without withdrawal of the nozzle from the anus. In this 
wise one or two quarts of water may commonly be introduced 
without exciting peristaltic action. The patient must remain 
quiet for a quarter to half an hour, when, if not sooner, the rec- 
tum will generally have expelled a portion, if not all, of the 
water. Dr. C. did not deem it wise for the patient to resist the 
expulsive action of the intestine, because it will thereby be in- 
cited to more violent efforts, which will counteract, in a measure, 
the beneficial action of the douche. He was unable to deter- 
mine how high in the intestine the water usually passes, but was 
satisfied that it occasionally traverses the whole large intestine to 
the ileo-csecal valve. Whether, in its ascent, the water is pro- 
pelled in part by retrostalsis, he was likewise in doubt, although 
he was fully convinced, by his own experience, that retrostalsis 
actually does occur under some circumstances. 

He generally directs that the douches shall be taken two or 
three times a day for two or three weeks, then to be intermitted 
for a week, although this last precaution he hardly thought nec- 
essary, for he had several times continued the injections four or 
five weeks without causing any ill effect upon the rectum. In 
a certain number of cases the douche had given rise to pain at 
the time of injection, or immediately afterward, when he had 
considered it as contra-indicated. 

PROF. FORDYCE BARKER, M. D., NEW YORK. 

In this disease this author directs absolute quiet in bed, and 
regards the danger of relapse as imminent if the patient gets up 
or moves much. If there be much pain in micturition, and the 
bladder be not thus entirely emptied, a catheter should be used. 
He believes that the bowels should be kept free from fsecal evac- 
uations by teaspoonful to tablespoonful doses of the compound 



474 COMPLICATIONS OF PAKTUKITION. 

magnesia powder, or the compound licorice powder, of the Ger- 
man Pharmacopoeia. If the pain be very acute in the commence- 
ment of the attack he usually overwhelms it by one hypodermic 
injection of morphia, and relies afterwards upon opium suppos- 
itories. The lower portion of the abdomen should be kept cov- 
ered by hot poultices of ground flaxseed, over which should be 
placed oiled silk, so that the poultice may retain its warmth for 
some hours. After the acute stage has passed away, cotton-wool, 
wet with laudanum, and also covered with oiled silk, may be 
substituted for the poultices. For some years he has discarded 
cups, leeches, and local depletion. 

In the cases which assume a subacute or chronic form, he has 
witnessed much benefit from injections of water into the vagina 
as hot as can be comfortably tolerated. In the employment of 
these injections, the patient should lie across the bed, with the 
hips well over its edge, and the feet upon two chairs. An India- 
rubber sheet should be placed w T ell under her, between her hips 
and her clothing, not only to prevent the latter from getting wet, 
but also to conduct the water, as it flows back from the vagina, 
down to a vessel which is placed on the floor. Then by the use 
of a Davidson syringe, two or three gallons of hot water may be 
injected into the vagina by the nurse. A still more easy method 
is to have a pail, with a stop-cock at the bottom, which connects 
with a long India-rubber tube, having a vaginal pipe at the end. 
This pail is placed on an elevation of a few inches above the 
patient, and the water is allowed to run in and out of the vagina. 
Not only do the patients generally derive great comfort from 
this warm poulticing, but if the physician immediately after 
makes a vaginal examination, he will need no argument to con- 
vince him what a powerful agent this is in modifying tissue. 

He employs quinine at an early period of this disease, giving 
it in as full doses as the patient can bear without inconvenience. 
If symptoms of suppuration, cachexia and hectic fever, come on, 
he relies on quinine and alcohol pushed to the point of tolerance, 
as internal remedies, and on surgical means for giving exit to 
the purulent collection. 



PELVIC CELLULITIS AXD PERITONITIS. 475 

So soon as the least fluctuation can be detected in any part of 
the pelvic cavity, Prof. B. directs that it be aspirated. He con- 
siders this a safe procedure — that it gives immediate relief to 
pain, that it shortens the duration of the disease, and is a pro- 
phylactic measure against disorganization of adjacent tissues. 

Puerperal Metritis. If he fii:ds the patient with pain in the 
hypogastrium, and the uterus larger than it should be at the 
time of the puerperal period and painful on pressure, the lochia 
diminished in a marked degree, or perhaps wholly arrested ; or, 
on the other hand, a return or positive increase in the amount 
of blood lost in the discharge, with a quick pulse, and more or 
less fever, he at once gives the following powder, well mixed, in 
a wineglass of sugar and water r, 

331. R . Tally's powder, 

Potass, bicarb., aa gr. x. 

Hydrarg. chloridi mitis, gr. v. M. 

If the skin be very hot and dry, and the pulse very hard, he 
may substitute the following : 

332. R, 



Pulv. potass, nitrat., 


gr.x. 


Pulv. gum camphor, 




Hydrarg. chloridi mitis, 


aa gr. v. 


Pulv. Jacobi veri, 


gr.iij. 


Pulv. opii, 


gr.j. 


Vel. morphias sulph., 


g*-£. 



M. 

He anticipates the following effect from these powders : The 
pain will be relieved ; nervous irritation allayed ; sleep induced ; 
fever subdued ; diaphoresis promoted ; and eight or ten hours 
after, an easy, revulsive cathartic action will follow. If cathartic 
action do not follow in ten hours, he orders a saline cathartic. 

He also directs that turpentine stupes be applied over the 
uterus and kept on until the patient insists on their removal, 
when cotton batting should be laid over the uterus, and this 
should be covered with oiled silk. If the patient complains of 
severe pain or burning from the turpentine, the cotton may be 
wet with laudanum. If the disease be of a sthenic type, he has 



476 COMPLICATIONS OF PARTURITION. 

derived great benefit from the application of six or eight wet 
cups over the uterus, but repudiates the use of leeches as very 
objectionable. If, after two or three days, there be not evident 
decrease in the uterine tumor, applies a blister over the uterus. 
In cases in which the uterus does not undergo the usual involu- 
tion, while the lochial discharge is profuse and sanguineous, he 
has derived advantage from the following combination : 

333. R . Ext, ergot, fld., 

Tinct. nucis vomicae, 

Tinct. ferri chloridi, aa f. ^ ss. 

Glycerine, 

Syrup aurant. cort., aaf. t ^j. M. 

Sig-. — Teaspoonful in a wineglassful of sugar and water every fourth hour. 
This usually reduces the size of the uterus, and diminishes the hemorrhagic 
lochia within twenty-four hours. 

He also regards vaginal injections as absolutely essential 
throughout the whole treatment of puerperal metritis. For- 
merly he used Labarraque's solution of the chlorinated sodium 
in warm water, as strong as the patient can bear without smart- 
ing ; recently he has employed the following : 

334. R. Acid carbolic, glacial, 

Glycerine, aa. f . f, j . 

Aquae purse, f.^vij. M. 

Sig. — A tablespoonful in a tumbler of warm water. 

If the lochial discharge be very purulent, and particularly if 
the odor be offensive, the injections should be used four, five, or 
six times a day. If the discharges be positively foetid, this 
author advises intra-uterine injections; and that intra-uterine 
injections be given with either a Scanzoni or French irrigator, or 
a fountain syringe, because we can thus adjust the force with 
which the fluid enters the uterine cavity. He believes that the 
fatal results which have ensued in the employment of intra- 
uterine injections, have accrued from their improper application. 
The danger seems to arise from the entrance of air into a vein, 
as in some cases, in which death has been sudden, or from the 



PELYIC CELLULITIS AND PERITONITIS. 477 

passage of fluid into the fallopian tubes, and peritonitis or 
phlebitis has ensued. 

In the suppurative and putrescent stages of puerperal metritis, 
our main reliance in connection with the intra-uterine injections 
must be on alcohol and quinine. He prefers giving the quinine 
in doses from 5 to 10 grains twice a day, instead of the 
smaller doses frequently repeated. The whiskey or brandy 
should be administered as freely as the patient can take it with- 
out any unpleasant effects. 

Puerperal Peritonitis. For this disease this author regards 
opium as the great remedy ; that it retards or arrests the peris- 
taltic movements of the bowels, gives the inflamed parts abso- 
lute rest, pain is relieved, nervous system tranquiiized, sleep 
secured, and thus the depression of the vital forces, resulting 
from the shock of the attack, is lessened. The opiate, therefore, 
should he given in such doses as to secure all these. The amount 
is only limited by the effect produced. It should be given freely 
until some narcotism is produced, and the respirations diminished . 
in number, but it should not be pushed beyond this point. If 
the respirations fall below twelve or fifteen, and the pupil be 
much contracted, the opiate should be withheld until these effects 
pass by. This line of treatment should be pursued until the 
inflammation is completely extinguished. 

Our author directs that we begin treatment by giving ten 
drops of Magendie's solution every hour, and gradually increas- 
ing the doses if the effects sought be not manifested. If the 
drops be rejected by the stomach, administer morphia hypoder- 
mically until the stomach will tolerate it. In some cases the 
tolerance of opium is remarkable. One case took 106 grains of 
opium and its equivalent in morphia during the first twenty- 
six hours, and in the second twenty-four hours 472 grains of 
opium. 

Prof. B. places also a high estimate on veratrum viride in al- 
laying vascular excitement. In conjunction with morphia, it 
reduces the number of pulsations without reducing the strength 
or increasing the degree of vital depression. 



478 COMPLICATIONS OF PARTURITION. 

For the pain in the abdomen and the tympanites, he applies the 
oil of turpentine on two thicknesses of flannel, previously dipped 
in hot water and wrung out as dry as possible ; this is to be left 
on as long as the patient can be induced to bear it. On taking 
off the flannel the abdomen should be covered with a light layer 
of cotton-wool, at least an inch or two in thickness and wet with 
laudanum. The turpentine stupes should be re-applied once or 
twice a day, if the abdomen show a tendency to again become 
distended and painful, and the cotton batting with the laudanum 
should be re-applied every few hours. In cases in which the 
symptoms of peritonitis have in a great measure subsided by 
apparent localization and induration, almost forming a circum- 
scribed tumor, our author has witnessed much benefit follow the 
application of a blister. He directs that it be applied in the 
morning, so that it can be well watched, and that it be taken off 
and a warm poultice applied as soon as vesication has fairly 
commenced. In this way the blister is well filled with serous 
.exudation, there is very little pain or soreness, and all danger of 
strangury is averted. 

In all cases in which the peritonitis is a complication of puer- 
peral fever, he has found quinine an efficient remedy, especially 
in cases in which the chills are recurrent, or when there are 
symptoms indicating a tendency to purulent exudation. He 
prefers giving it in one or two impressive doses during the day 
to the small and frequently repeated doses — that is, give about 
5 to 10 grains in the morning and from 10 to 20 in the even- 
ing. There is a decided tolerance to quinine in this disease. 
He also values alcohol in this disease. It renews the nervous 
forces, which are generally in a state of extreme prostration, 
probably by the cerebral hyperaernia induced by the alcohol. In 
this, as in other diseases with great depression, patients are able 
to bear four, five, or even ten times the quantity that could be 
taken in health, without the least approach to intoxication. It 
diminishes waste, and thus tends to cause a diseased structure, in 
which vital changes are abnormally active, to return to its nor- 
mal and much less active condition. With the whiskey or 



PELVIC CELLULITIS AKD PEEITONITIS. 479 

brandy he combines veratrum viride if there be considerable 
vascular excitement. This combination often reduces the pulse 
when either of these agents individually fails. 

He also recommends the following vaginal injection : 

335. R. Glycerins*, 

Acid, carbolic, glacial, aa f.,lj. 

Aqua? puree, f-^ v j- M. 

Sig. — A tablespoonful added to half a pint of warm water, and carefully 
injected into the vagina twice a day. If the lochia be very abundant and 
foetid, the amount of carbolic acid may be doubled or even quadrupled. 

The food should, consist of beef-tea, panada, caudle, milk, and 
lime-water. 

Our author has no confidence in the aplastic properties of mer- 
cury ; yet in cases in which there is vomiting of bilious matter 
he gives 10 grains of calomel well rubbed up with 20 grains 
of bicarbonate of sodium. 

Although generally averse to venesection in this disease, he 
believes it is strongly indicated in some of the more sthenic 
cases, and employed with good results. 

Stimulants should be given so soon as feebleness of the pulse, 
clamminess of the surface, profuse perspirations, or cold extremi- 
ties, are noticed. Stimulants decrease the frequency and increase 
the force of the pulse. 

Another important point, is nutrition. Food in a liquid form 
should be taken as freely as it can be digested and assimilated. 
Milk, eggs, gruels, beef-tea, mutton broth, chicken soup, given 
every two or three hours, are useful. 

Purgatives, as a rule, are not desirable. Sometimes, however, 
when the tongue has a thick pasty coat, and there is a great deal 
of bilious vomiting, he gives a powder composed of from 5 to 
10 grains of calomel, and 20 grains of the bicarbonate of 
sodium. 



Puerperal Metritis. He advises in this disease the horizontal 



480 COMPLICATIONS OP PAETUEITIOX. 

posture ; avoidance of all needless movements, and the use of 
enemata. When the abdominal pain is great, leeches may be 
applied to the abdominal wall ; but a speedier effect is obtained 
by ice-water compresses, and the ice-bag. When this can be 
dispensed with, inunction with 15 grains of mercurial oint- 
ment should be made every two hours until salivation occurs, or 
with iodide of potassium ointment, together with warm compresses. 
If the discharge is offensive, inject with tar-water or permanga- 
nate of potassa, and with mucilaginous fluids. Promote absorb- 
tion in every way, if there is effusion. If there is pus, evacu- 
ate speedily. When the fever subsides, give diuretics and iodide 
of potassium, 5 grains three times a day. 

PEOF. WM. LEISHMAN, M. D., GLASGOW. 

The most important point is to relieve pain. When above 
the pelvic brim, poultices and fomentations with laudanum are 
most grateful. When vaginal, the douche, or medicated pessa- 
ries, may be used. Beextjtz strongly urges the use of conium 
internally. The bowels are to be kept free, and the comfort of 
the patient is greatly aided by injection of soap and water, to 
which turpentine may be added, given every night. Leeches to 
the locality may prevent suppuration. Beentjtz insists that 
they should be applied directly to the uterus. Apply three at 
a time, and, if necessary, encourage the flow by a warm hip- 
bath. 

In addition to the remedies already mentioned by others, when 
not contra-indicated, use the per chloride oj mercury, 1/ 16 of a 
grain, until faint mercurialization occurs. Iodide of potassium, 
or the tincture of iodine, may be used with little hesitation. 
Blisters may be used, but iodine is preferable, used externally, 
so as to continue its effects within moderate bounds for a long 
period. 

KESUME OF KEMEDIES. 

Aconite is recommended by many (F. 330). Baetholow com- 
bines it with opium. 



PELVIC CELLULITIS AND PERITONITIS. 481 

336. R. Tinct. aconiti rad., f.^ij. 

Tinct. opii deod., f-.^vj- M. 

Dose, eight drops in water every hour or two. This in perito- 
nitis. 

Acidum Carbollcum in vaginal injections. (F. 334, 335.) 
*Ammonii Murias is believed by many to act powerfully as a 

sorbefacient. 
Camplwra, in combination with nitrate of potassa and opium, is 

used by a number of practitioners. (F. 332.) 
Conium is urged by Bernutz. (P. 480.) 

* Hydrargyrum, either by the mouth or by inunction, is generally 

employed. 
*Iodinium. This remedy is highly useful, externally applied to 
the abdomen. 

*Morphia, in full doses, and combined with quinia, is regarded 
by many practitioners as the best means of treatment. 
Bartholow says that the hypodermic injection of 
morphia will sometimes jugulate peritonitis, if given 
at the outset. If the period for such a favorable result 
has passed, the course and duration can be greatly 
modified by opium judiciously used. The quantity 
will be determined by the effect ; the pain should be 
relieved, the pupils somewhat contracted. 

*Potassii Iodidum, is very useful to aid in the absorption of effu- 
sions. 

Potassii Nitras is useful when the skin is hot and dry, and the 
pulse hard. 

* Quinia must be given in large doses, and continued. 
Terrebinthinaz Oleum, in the form of stupes, during the acute 

stage, is recommended by Bartholow and others. 
Veratrum Viride, either alone or combined with morphia, to 
allay vascular excitement. 

other measures. 

Aspiration in pelvic exudations, although frequently employed, 
has not yielded very satisfactory results. Cellulitis 
not unfrequently follows. 
31 



482 COMPLICATIONS OF PARTURITION. 

Blisters favor absorption, and should be frequently repeated. 

Cold, in peritonitis, is recommended in the form of the ice-bag 
by Winckel and Bartholow. The latter says when 
the inflammation is recent, the abdomen may be cov- 
ered with an ice-bag. It is proper to interpose a nap- 
kin between the skin and the bag. 

Injections of hot water are highly lauded, especially by Prof. 
Barker. They act like local poultices, and certainly 
are capable of great good. 

Vaginal injections of carbolic acid, permanganate of 
potassa, and chlorinated sodium, are also extremely 
valuable as disinfectants and antiseptics. 

Leeches applied to the groin or to the hemorrhoidal veins may 
be employed. Never to the uterus. Barker discards 
them entirely. 

Poultices are very comforting by their warmth and moisture. 
These may be greatly aided by the addition of lauda- 
num, belladonna, etc. 

Best. This must be absolute, and not departed from until all 
danger of a relapse has disappeared. 

Section, abdominal. Mr. Lawson Tait advocates the principle 
of opening and draining the various conditions of 
suppuration classed as " pelvic abscess." He points 
out, and quotes Dr. West in support, that in very 
many of these cases the abscess opens into the rectum 
or other part of the intestine, the bladder, or round 
amongst the muscles of the anterior abdominal wall. 
When such openings are established either death occurs 
or recovery is extremely protracted. Even when the 
abscess opens into the vagina or can be tapped from 
that canal, the recovery is frequently prolonged to an 
extent not commensurate with the size of the abscess. 
He opens from above, carefully stitching the lips of the 
opening to the abdominal wall. He has reported 
six cases where the patients were restored to health 
in thirty days. He concludes that it is neither a 
difficult nor a dangerous operation. 



PHLEGMASIA DOLENS. 483 

PHLEGMASIA DOLENS. 

DK. JOSEPH AM ANN, OF MUNICH.* 

The prophylaxis in this disease is very important. If signs 
of fever and pain in the limb appear, the patient should remain 
in bed, receive no visits, and observe a strict diet. Every pre- 
caution should be taken to remove all causes of excitement or 
irritation, moral or physical. 

An important point is the position of the patient ; she should 
lie so that the leg of the affected limb is more elevated than its 
thigh ; for this purpose, the leg should be laid on a soft elastic 
cushion, the knee being bent. The bowels should be moved by 
a moderate laxative. Venesection, formerly employed, is now 
out of date. At most, a few leeches may be applied near the 
painful point, in order to reduce the hyperemia. 

Of local applications, the most efficient are — cloths wrung out 
in lead-water, or ice- water ; and, later, inunction of an oint- 
ment composed of equal parts of mercurial ointment and lard. 
Of the latter, a piece the size of a bean may be rubbed into the 
thigh and groin twice daily, until a mercurial impression on the 
gums is noticed, after which frictions with camphorated oil and 
alcohol may be substituted. When the fever has disappeared, 
the swelling may be painted with tincture of iodine, and the 
limb bandaged. 

The patient should keep her bed for some days after all fever 
has disappeared, as a part of the thrombus may be loosed by 
active motion. 

In that form of the disease, when there is subcutaneous in- 
flammation of the limb without thrombosis in the veins, the 
same precautions in putting the patient to bed should be ob- 
served, and the limb similarly rubbed with dilute mercurial 
ointment. But should speedy improvement not follow these 

* Klinik der Wochenbettkrankheiten. 1877. 



484 COMPLICATIONS OF PARTURITION. 

measures, the physician should not delay to make free incisions 
in the skin, to give vent to the pus which has formed, and to 
lessen the tension and swelling. A rapid change for the better 
will follow this measure. Applications of cloths wrung out in 
warm chamomile tea, and washing the wound with weak carbolic 
acid lotion, (one per cent.,) will appropriately follow. Of course 
the general strength must be supported by wine, soups, milk, etc. 

DR. J. L. POWERS, OF IOWA. 

This practitioner (Trans. Iowa State Soc, 1880,) has found 
great benefit from applying a tobacco salve or plaster to the limb 
throughout its whole length. Within twenty-four hours the 
painful stasis is relieved, and in a few days the patient is fully 
restored. The formula he uses is the following : 



337. R . Navy plug tobacco, 


J pound. 


Tallow, 


I « 

4 


Bosin, 


i " 


Lard or olive oil, 


i " 


Beeswax, 


i " 


Balsam fir, 


1 ounce. 


Burgundy pitch, 


J pound. 


Vinegar, 


2 pints. 


Water, 


i pint. 



Cut up the tobacco and soak it in the water till soft ; add one pint of the 
vinegar, boil, strain, and add the second pint ; boil and strain, and add the 
wax, rosin and lard. Boil till all the water evaporates, add the balsam fir, 
and stir till cool. 

A plan recommended by Dr. CrichtOjS", in a paper read be- 
fore the British Medical Association in 1871, is to apply a solu- 
tion gr. xxx. to 1 j. of the sulphate of iron, using it as hot as it 
can be borne. This has been tried by some American physicians, 
and is said to be followed by a marked diminution of the pain 
and swelling, and to be one of the best local applications. (Al- 
bany Medical Annals, August, 1880.) 



The disease tends to a spontaneous recovery, and generally dis- 



PHLEGMASIA DOLENS. 485 

appears without serious consequences. Hence any treatment 
which disturbs the system or the normal functions, is objection- 
able. The indications are : 

1. To ajjay the irritation of the nervous system, which can 
best be done by full doses of opium where there is no idiosyn- 
crasy to prevent its use. 

3. To suppport the system by nutritious food, stimulants and 
tonics. Of the last-mentioned, quinine and iron hold the first 
place. 

Only in cases where special indications exist should catharsis 
be induced, or cups be applied over the kidneys." In nearly all 
cases there is no occasion whatever for these. 

After the first two or three days, the disease becomes mostly 
local. The patient should keep quiet, the limbs be elevated at an 
angle above the trunk by raising the lower part of the mattress, 
and where there is hyperesthesia of the surface and pain in the 
deep-seated nerves, much relief will be obtained by gently rub- 
bing the surface with a liniment like the following : 

338. R. Linimenti saponis co., f.5 vj. 

Tincturse opii, f.jfiss. 

Tinct. aconiti radicis, i.f> ss. 

Extracti belladoimse, % ss. M. 

For a liniment. 

The rubbing with this should be gentle and continued for fif- 
teen or twenty minutes, and always toward the trunk. This may 
be repeated every six hours, after which the leg should be envel- 
oped in cotton batting and covered with raw silk. 

After the period of acute tension, the leg should be examined 
for localized phlegmon, and if any circumscribed collection of 
pus be discovered, it should be evacuated at once ; otherwise the 
tonicity of the tissues will best be promoted by applying a roller 
bandage, beginning at the toes and carrying it up the whole 
length of the limb. This should be worn so long as there is 
any tendency to oedema of the foot and leg. The patient should 
not be permitted to walk until all evidence of local disease has 
disappeared. 



486 COMPLICATIONS OF PARTURITION. 

PROF. W. S. PLAYFAIR, M. D., LONDON, 

Agrees in the main with the treatment above recommended. 
For the relief of the pain, he has found one of the ]jest meas- 
ures to be wrapping the entire limb in linseed meal poultices, or 
in warm flannel stupes, the surface of which may be freely 
sprinkled with laudanum, chloroform, or belladonna liniment. 
Blisters, leeches, or any form of counter-irritation or abstraction 
of blood, he does not approve of. Internally, he thinks chlo- 
rate of potassa, with dilute hydrochloric acid, quinine, ammonia 
and iron, are the drugs most likely to prove of service. As an 
anodyne, generally nothing answers so well as the hypodermic 
injection of morphia. 

At a later stage, support with a roller may be combined with 
gentle inunctions of weak iodine ointment. And shampooing 
or rough friction of the limb should be avoided, on account of 
the danger of producing embolism. The occasional use of the 
electric current is said to promote absorption. 

PROF. F. WINCKEL, M. D., DRESDEN. 

The leg must be raised a little higher than the thigh, and the 
knee flexed ; the foot and calf supported by pillows to prevent 
the rotation outward ; apply compresses of lead-water ; rub 
over the skin about Poupart's ligament a piece of ungent. hy- 
drarg. the size of a bean, three times a day. If the pain is 
acute, add laudanum to the lead- water. Open any vesicles that 
may form, and evacuate the serum. When the pain and swell- 
ing subside, paint with tinct. iodine or Lugol's solution, and 
cover with wet compresses ; bandage the leg to produce reduc- 
tion. 

Bcer claims good results from a blister the width of two 
fingers, around the thigh, just above the knee. 

A proper support of the limb will be required when the 
patient leaves the bed. 

Bandaging the limb, beginning at the toes and proceeding to- 



PHLEGMASIA DOLENS. 487 

ward the body, is a valuable part of the treatment. Some pre- 
fer to bandage with flannel cloths wrung out of hot water. 

Position is an important aid in the treatment. The limbs 
should be elevated on pillows until they form an angle of thirty 
or forty degrees with the body. This has been followed by ex- 
cellent results in the practice of Dr. J. C. McMechan, of Cin- 
cinnati. (Cin. Lancet and Clinic, January, 1881.) 



488 COMPLICATIONS OP PARTURITION. 



MILK FEVER. 

This affection, formerly so much dreaded, and believed so fre- 
quently to occur on the third day, on the occasion of the appear- 
ance of the milk, is now by some regarded as virtually a myth. 
In many instances, a slight increase of heat, pulse, etc., occur- 
ring at the time when the secretion of the milk commences, is 
regarded as a true form of fever, and treated with so much 
energy as frequently to induce a real disorder more or less 
serious. The best authorities now agree that the better regimen 
allowed to the lying-in woman, and the more sensible mode of 
conducting labor which at present has become the practice, pre- 
vents many of these abnormal tendencies. 

Playfair, Winckel, Grunewall, D'Espine, and others, 
agree in this belief, or regard the fever as a mild septicaemia. 
Graily Hewitt believes that it only occurs where the patient 
is weakened either by a prolonged and exhausting labor, from 
hemorrhage, or from insufficient nourishment. 

)R. JOSEPH AM ANN, OF MUNICH.* 

This author observes that while no doubt the term "milk 
fever," febris lactea, was in former days quite too widely and 
loosely used, he cannot, on the other hand, consent with 
Winckel and others, to banish it from midwifery. It is his 
observation that in at least 6 per cent, of parturients a febrile 
condition appears between the third and fourth day post partum, 
lasting from 24 to 48 hours, without having any other assigna- 
ble cause than the swelling and irritation of the mamtnse pro- 
duced by an impeded flow of the secretion. 

Similar feverish conditions arise from prolonged constipation, 
collection of gas in the intestine, severe loss of blood, impedi- 

* Klinik der Wachenbettkrankheiten. 



MILK FEYEE. 489 

ments to the discharge of the lochia, mental excitement and the 
rheumatic diathesis. 

The indications for treatment have reference to the causes 
here assigned. When the flow of milk is impeded the child 
must be diligently applied to the breast or suction by an adult or 
a breast-pump substituted. The breast may also be rubbed 
gently with oil of almonds, or covered with a spermaceti plaster, 
or compressed with a bandage, the gland being surrounded with 
wadding or tow. The bowels should be acted on, a dose of cas- 
tor-oil, say f. 3 i., in four spoonfuls of black coffee. When there 
is caprostasis, large enemata should be used so as thoroughly to 
wash out the lower bowel. 

When the lochia are scanty, involution delayed or a danger of 
septic absorption present, the remedy called for is ergot, and 
along with this, the vagina should be thoroughly washed out 
two or three times daily with luke-warm water containing half 
per cent, of carbolic acid. Should the febrile symptoms not 
yield promptly to these measures, quinine should be adminis- 
tered, grs. xxx.-xlv., in divided doses, within two days. 

If it is believed that the feverish symptoms are of nervous or 
mental origin, a sufficient treatment will be to enjoin entire rest 
and quiet, and to exhibit small doses of morphia. 

Rheumatic symptoms demand special attention to protection 
from drafts, etc. ; while fever from loss of blood indicates con- 
centrated nourishment, quinine, coffee and stimulants. 

PEOF. FOEDYCE BAEKEE, M. D,, 

Regards it as an exceptional incident of child-bed, and gives the 
following prophylactic measures : 

Secure to the patient some hours of sound and refreshing 
sleep immediately after delivery. 

Give such food as will be abundantly nutritious, without over- 
taxing the digestive organs. 

Apply the child to the breast as soon as the patient has re- 
covered from the exhaustion of labor. 



490 COMPLICATIONS OF PARTURITION. 

"When the symptoms of milk fever present themselves, if the 
bowels have not been fully moved, give a saline laxative ; sub- 
due vascular excitement, and promote diaphoresis. The follow- 
ing is very effective : 

339. R . Tinct. aconit. rad., # gtt. xx. 

Antimonii et potassii tartratis, gr. ij. 

Spirit, etheris nitrici, 
Syrupi simplicis, aa £,lj- 

Aquae aurantii flor., f.% ij. M. 

A leaspoonful in a wineglassful of sugar and water every two hours. 

Have the nurse gently, but thoroughly, rub the breasts from 
the circumference toward the nipple with warm sweet oil every 
two hours till the distention has subsided, allay pain and. nervous 
irritability, and secure sleep by a diaphoretic anodyne, as 8 to 
18 grains of compound ipecac, powder or of Tully's powder. 

Prof. Karl Schroeder and Prof. W. Leishman, agree that 
the milk fever is due to the distention of the breasts, and regard- 
less of the amount of fever, these organs demand prompt atten- 
tion, as by keeping them soft, frequently emptying them, applying 
evaporating lotions, relieving the dragging, etc., by suspending 
the inflamed gland ; in short, by removing the cause, the fever 
itself is removed. 



PUERPERAL CONVALESCENCE. 491 



PUERPERAL CONVALESCENCE. 



PROF. 



Daring this period, the chief indications are: First, the res- 
toration of the pelvic organs to their normal condition, and the 
development of lactation. The accomplishment of the first in 
the multipara is usually attended with uterine contractions of an 
intermittent character. Our author thinks much can be accom- 
plished by way of preventing their occurrence; that they are 
usually the result of coagula in the cavity of the uterus which 
distend its walls, and excite spasmodic contractions. The reten- 
tion of these may be obviated by firm pressure over the fundus 
during the time the trunk of the foetus is being expelled, and 
maintained until the placenta is delivered, and a permanent con- 
traction of the uterus is secured. If the second stage is too rapid, 
or too prolonged, he gives a teaspoonful of the fluid extract of 
ergot, just as the delivery of the child is taking place. If the 
after-pains come on a few hours after the delivery, the first 
pressure should be renewed so as to expel coagula. It often 
gives relief. At a late period this must not be attempted, for 
fear that it may excite irritation aud inflammation. He then 
relies on the following formula, known as Tully's powder : 



M= 



The severe after-pains sometimes occurring a day or two after 
labor, and excited by the pressure of flatus, must not be con- 
founded with peritonitis. This diagnosis is easily made ; while 
a slight touch causes pain, the pain entirely disappears upon con- 
tinued pressure ; it returns as soon as the pressure is removed. 
On the other hand, the pain due to peritonitis will be increased 



340. K . Pulv. g. camphor, 
Cretse pp., 
Pulv. glychrrh., 
Morphise sulph., 


aa 




ose. — The same as Dover's powder. 







492 COMPLICATIONS OF PARTURITION. 

in ratio to the pressure made. After-pains due to flatus are 
most speedily relieved by turpentine stupes and turpentine ene- 
mata. Sometimes after-pains of a purely neuralgic character are 
encountered. They do not yield to opium in its fullest doses, 
but are relieved by quinine and chloroform liniment. He gives 
the quinine in doses from 5 to 10 grains, night and morning, 
and applies the liniment by saturating a piece of flannel of dou- 
ble thickness. The formula for the liniment is : 



341. R. Ckloroformi, f.|j. 

Liniment, saponis eo., f. J vj. M. 



RETARDED INVOLUTION. 

If the uterus can be felt above the pubes a few days after par- 
turition, our author prescribes the following : 

342. R . Ext. ergot, fluid., 

Tinct. nucis vomicae, 
Tinct. ferri chloridi, 

Tinct. cinnamom. cort., aa £§j- ^M. 

Sig-. — Tablespoonful in a wineglassful of sugar and water four times a day. 

LAXATIVES FOE PUEKPEEAL WOMEN. 

PROF. FORDYCE BARKER, M. D., NEW YORK. 

Our author opposes the indiscriminate dose of castor oil, and 
very truthfully states that it often excites hemorrhoids. He 
highly recommends the following pills : 



343 .R . Ext. colocynth co., 

Ext. hyoscyami, 
Pulv. aloes soc., 




gr. xv. 
gr.x. 


Ext. nucis vomicae, 
Podophyllin, 
Pulv. ipecacuanhas, 
Ft. pil. No. xii. 


aa 


gr.v. 



M. 



Two of these usually secure the desired evacuation of the 



PUERPERAL CONVALESCENCE. 493 

bowels. One of these may be taken daily to keep the intestinal 
canal free from fsecal accumulations. 

When there are flatulence and severe after-pains in conse- 
qence of constipation, he recommends the following : 

344. B ■ Ext. sennse fluid., 

Syrup, zingiberis, aa f'3 v j' 

Tinct. jalapae, f.Jfss. 

Tinct. nucis vomicae. gtt. xl. M. 

Sig. — A tablespoonful in a wineglassful of sugar and water. 

Diet. Our author very positively dissents from the formerly 
pursued plan of restricting the diet of the parturient woman to 
toast and tea. He very judiciously remarks that at this epoch of 
maternity, her wearied and exhausted system, with the additional 
taxation of lactation, requires food to meet the new demand for 
the nourishment of her offspring, and to restore her own strength 
and vigor. He further objects to the application of any arbi- 
trary rules to all women, and enjoins the necessity of indvidual- 
izing each case and adapting the diet to the various conditions 
of the patient. Some are very much benefited by an immediate 
restoration to their former diet, while others need more restric- 
tions, and the adaptation of the diet to the various pathologi- 
cal conditions evinced. It should, however, in all cases be as 
abundant as the digestive organs can digest, and the assimilative 
organs can appropriate without inconvenience, and of nutritious 
quality. 



494 COMPLICATIONS OF PARTURITION. 

COCCYGODYNIA. 

DR. H. HILDEBRANDT, OF KONIGSBERO.* 

This painful affection can be materially relieved or wholly 
cured in about one-half the cases by medical and hygienic means; 
the remaining one-half have only to hope from a surgical opera- 
tion. When there is direct injury to the coccyx from confine- 
ment, horseback exercise, or direct violence, less can be expected 
from medication. 

In fresh cases, abolute rest on the sides, aperient medicines so 
as to secure loose stools, and local antiphlogistic measures are 
demanded. Some leeches should be applied either side of the 
coccyx, followed by an ice-bag. As soon as their bites are 
healed, tincture of iodine should be repeatedly painted over the 
part. Every sort of pressure on the bone must be sedulously 
avoided. 

In old cases, the treatment may be begun in the same manner. 
The continued use of laxative mineral waters is beneficial ; and 
to relieve the pain, recourse must be had to opium suppositories 
or subcutaneous injections of morphia, preferably the latter, as 
they do not so much tend to produce constipation. Counter- 
irritation by the actual or gal va no-cautery has proved a benefit. 
Some cures have resulted from methodical massage ; and as 
sometimes the suffering is strictly rheumatic in origin, colchicum 
and vapor-baths are appropriate in such instances. 

PROF. J. MATTHEWS DUNCAN, M. D., OF LONDON.f 

This writer does not think well of the term " coccygodynia," 
and prefers that of "painful sitting." True coccygodynia is neu- 
ralgia of the coccyx, a common disease in both sexes. 

*Part VIII. of Billroth's Handbuch der Frauenkrankheiten. 
| Lecture on Diseases of Women, 1880. 



COCCYGODYNIA. 495 

This form of the disease is generally easily cured. The treat- 
ment is the use of laxatives, hot bathing, and sedative applica- 
tions. In a severe and persistent case, it is proper to try the 
hypodermic injection of morphia. 

Other cases arise from the injury of the joint or ligaments of 
the coccyx, or from a rheumatic inflammatory condition of the 
ligaments. In such cases, where the treatment above described 
fails, it may be well to divide the sacro-sciatic ligaments at their 
attachments to the coccyx. This frequently fails, but once in a 
while succeeds. 

In dislocation of the coccyx there is no permanent pain or ten- 
derness, but only inconvenience w T heu it is backward; when for- 
ward it is painful. Reduction in such cases is usually not prac- 
ticable. Removing the coccyx altogether has been recommended. 
This has not proved a satisfactory proceeding ; yet in some cases, 
not very easily defined, it does present itself as a probable means 
of getting rid of the annoyance. 



In a lecture on this complaint (printed in 1880,) reviews its va- 
rious causes and treatment. 

Cases of coccygodynia, which arise from climatic causes, may 
be similar to cases of myalgia in any of the other muscular 
structures of the body, will be of rather an acute type, and 
yield to very much the same treatment as is employed in my- 
algia. 

Chronic cases of a mild character will sometimes yield to 
epispastics or mild blistering, and anodynes administered either 
by the mouth or rectum. 

Topical application of opium, or belladonna plaster, or chloral 
liniment, may often prove of service, but when the pain is se- 
vere, more potent remedies are required, such as the hypoder- 
mic injection of morphine, or atropine, or a combination of the 
two. 

The hypodermic injection of morphia over the coccyx may 



496 COMPLICATIONS OF PARTURITION. 

overcome the irritability and painfullness of the muscles, and pos- 
sibly effect a cure. But if the case does not improve in a short 
time under some of these modes of treatment we, must have 
recourse to surgical art. 

The mode of operating for amputation of the coccyx is as fol- 
lows : Anaesthetize the patient, and place her upon her right side, 
that the index-finger of the left hand may be introduced into 
the rectum to press the coccyx backward, and as a guide during 
the progress of the operation. 

Cutting down to the bone with the scalpel, it can be further 
separated from its attachments by means of scissors, or a knife, 
as we may choose, and selecting the location where amputation 
is to be made, we can then disarticulate at the joint, or follow 
the mode of Simpson, who used the bone-forceps and cut the 
bone without reference to joints. 

By one of the procedures mentioned, namely, separation or 
amputation, we can confidently expect a cure ; and as neither is 
attended with danger, we are also able to class these operations 
among the satisfactory ones of surgery. 



CHAPTER III. 

DISEASES OF THE MAMMARY GLANDS AND 
OF LACTATION. 

Mastitis; Inflammation of the Breasts — Mammary Tumors — 
Mammary Neuralgia (Mastodynia) — Galactorrhosa — Agalac- 
tia and Oligolactia — Diseases of the Nipple. 

MASTITIS AND MAMMARY ABSCESS. 

PEOF. H. BILLROTH, OF VIENNA.* 

The treatment of acute mastitis consists in putting the patient 
to bed, on low diet so long as there is fever, and in properly 
bandaging the breast. To relieve the pain and to prevent the 
formation of an abscess, warm poultices are required, and if lacta- 
tion is interrupted, mercurial ointment or iodine ointment may- 
be applied. Prof. B. disapproves of leeches and ice-bags. To 
check the secretion of milk he gives purgatives or iodide of 
potash. 

Massage of the breasts as practiced by many midwives is pain- 
ful and may be injurious. The opening of the abscesses should 
always be done with a knife, and there is no advantage in delay. 
Very great advantages are here derived from the antiseptic treat- 
ment. The breast is first cleaned with soap, then washed with a 
.weak solution of carbolic acid and an incision one centimetre long is 
to be made in the direction of the radius of the breast. The 
drainage tube is then inserted, the pus withdrawn the breast 
again bathed with the carbolic acid lotion, and the breast com- 
pressed from all sides with antiseptic gauze. 

* Handbuch der Frauenkrankh&iten. 

32 497 



498 DISEASES OF MAMMARY GLANDS AND LACTATION. 

If the antiseptic precautions are fully carried out, one will 
never see such cases as were common heretofore, in which the 
breasts were undermined for months with abscesses, and the 
woman suffered untold misery. 

Even in old cases which have been allowed to open themselves 
or were incised without antiseptic precautions, we need no longer, 
as heretofore, have recourse to long incisions. The operation 
should be conducted as above, the opening dilated sufficient to 
admit the finger and the point of an irrigator; the abscesses 
should then be washed out with a three per cent, solution of 
carbolic acid till it flows clear, the walls between the internal 
abscesses being broken down by the finger, and drains being 
placed in various openings. An antiseptic bandage is then ap- 
plied. It is needless to say that anaesthetics are required. 

As a consequence of mastitis, fistulse in the breast are com- 
mon and may continue many months. The usual treatment of 
these is to cauterize them with nitrate of silver and inject strong 
or weak solutions of carbolic acid or iodine. Some can also be 
remedied by drainage and compression. 

PEOF. FORDYCE BARKER, M. D., NEW YORK. 

This author endeavors to abort the abscess by tincture of iodine 
painted over the inflamed breast. 

If unsuccessful in this he applies, over the breast, bread and 
milk or linseed meal poultices as hot as can be borne. Usually 
he prefers warm water dressings made by soaking two folds of 
lint in warm water, and these covered over by oiled silk. 

He denounces the routine practice of rubbing the breast in 
mastitis as absolutely pernicious. 

As soon as the abscess points and the fluctuation can be de- 
tected, it should be opened in the most dependent point, care- 
fully avoiding, however, the areola. 

To relieve pain and procure rest, he gives ten grains of Dover's 
or Tully's powder. 



MASTITIS, 499 

When there is an epidemic or endemic tendency, he avoids all 
depressing agents and gives full doses of quinine. 

In the treatment of the sub-glandular form the same general 
principles should govern us as to constitutional measures, as in 
the subcutaneous variety. 

He has no confidence in any topical treatment. The sole 
remedial measure of value, is to secure the early discharge of 
the pus by incision. If the conditions of the case will admit of 
an election, the opening should be made at some inferior point 
in the circumference of the breast, so as to prevent secondary 
inflammation of the glandular structure or of the subcutaneous 
areolar structure. Sometimes the signs of sub-glandular abscess 
existed, but no fluctuation ; he has detected the presence of pus 
by lifting up the gland from the thorax and passing between 
them an exploring needle. He then makes a sufficiently large 
incision with a long tenotomy knife. But if the abscess point 
on the anterior surface, then the opening must be made where 
the fluctuation exists, and care must be taken to prevent its 
closure before the pus is all discharged, by the insertion of a 
tent. 

Glandular inflammation or mammary adenitis presents two 
types ; one rapid in its course, in the other the inflammatory pro- 
cesses are in tardy succession. In the former, resolution may be 
secured in a month ; in the other, the period of several months 
may be required. 

The first requires vascular sedatives, saline laxatives, anodynes 
and an antiplogistic regimen; while in the other, tonics, stimu- 
lants and nutritious di«t are indicated. Nursing must be 
forbidden, as the pain and excitement thereby produced will 
aggravate the inflammatory condition. If, however, the secretion 
of milk be active, accumulation of this fluid must be avoided, 
the breast must be disgorged by artificial means. Rub the breast 
with the hand lubricated with sweet oil until the breast is soft 
and all nodulated indurations have disappeared. To prevent 
the return of the lacteal engorgement, he then covers the breast 
with the extract of belladonna, softened with a little glycerine. 



500 DISEASES OF MAMMARY GLANDS AND LACTATION. 

If these means do not secure resolution, the abscess must be 
opened when the presence of pus is determined. Then by adhe- 
sive straps applied so as to support the breast and firmly com- 
press it from circumference to the centre, he secures the relief 
of engorgement of other lobules, the removal of indurations, 
the prevention of purulent infiltration into the adjacent areolar 
tissue, and the formation of obstinate fistulous sinuses. 

PROF. W. S. PLAYFAIR, M. D., LONDON, 

Urges that much may be done to prevent abscess by removing 
engorgement of the lacteal ducts when threatened, by gentle hand 
friction with warm oil. Combat feverishness by gentle salines, 
minute doses of aconite, and large doses of quinine, and relieve 
pain by opiates. Confine the patient to bed, and support the 
breast by a suspensory bandage. Warmth and moisture are 
best to relieve local pain, as hot fomentations, light linseed meal 
poultices, or bread and milk ; and the breast may be smeared 
with extract of belladonna rubbed down with glycerine, or the 
belladonna liniment may be sprinkled over the poultices. Gen- 
erally the pain produced by nursing is so great as to prevent 
the child being put to that side, and the tension must be relieved 
by poultices. When pus forms, remove it as soon as possible ; 
nothing is to be gained by waiting till it nears the surface ; 
delay leads to greater spread of the disease. 

The antiseptic method of operation should always be em- 
ployed, as thus, in place of weeks or months, the abscess will be 
closed in a few days. Mr. Lister's method is so perfect that 
no more can be desired. "A solution of one part of crystallized 
carbolic acid in four parts of boiled linseed oil, having been pre- 
pared, a piece of rag from four to six inches square is dipped 
into the oily mixture, and laid upon the skin where the incision 
is to be made. The lower edge of the rag being then raised, 
while the upper edge is kept from slipping by an assistant, a 
common scalpel or bistoury dipped in the oil is plunged into^the 
cavity of the abscess and an opening about three-fourths of an 



MASTITIS. 501 

inch in length is made, and the instant the knife is withdrawn, 
the rag is dropped upon the skin as an antiseptic curtain, beneath 
which the pus flows out into a vessel placed to receive it. The 
cavity of the abscess is firmly pressed, so as to force out all exist- 
ing pus as nearly as may be (the old fear of doing mischief by 
rough treatment of the pyogenic membrane being quite ill- 
founded) ; and if there be much oozing of blood, or if there be 
considerable thickness of parts between the abscess and the sur- 
face, a piece of lint dipped in the oil is introduced into the in- 
cision to check bleeding and prevent primary adhesion, which is 
otherwise very apt to occur. The introduction of the lint is 
effected as rapidly as may be, and under the protection of the 
antiseptic rag. Thus the evacuation of the original contents is 
accomplished with perfect security against the introduction of 
living germs. This, however, would be of no avail unless an 
antiseptic dressing could be applied that would effectually pre- 
vent the decomposition of the stream of pus constantly flowing 
out beneath it. The following may be relied upon as trust- 
worthy : about six teaspoonfuls of the above-mentioned oil are 
mixed with carbonate of lead to the consistence of a firm paste ; 
it is, in fact, glazier's putty with the addition of a little carbolic 
acid. This is spread upon a piece of common tin-foil, about six 
inches square, so as to form a layer about a quarter of an inch 
thick. The tin-foil is placed upon the skin so that the middle 
of it corresponds to the position of the incision, the antiseptic rag 
being removed the instant before. The tin is fixed securely by 
adhesive plaster, the lowest edge being left free for the escape of 
the discharge into a folded towel placed over it, and secured by 
a bandage. The dressing is changed once in twenty -four hours, 
but if the abscess be large, it is prudent to see the patient twelve 
hours after it has been opened, when, if the towel be much 
stained with discharge, the dressing should be changed to avoid 
subjecting its antiseptic virtues to too severe a test. After this, 
one daily dressing is enough. The changing of the dressing 
must be done as follows : A second piece of tin-foil is spread 
with the putty, a rag is dipped in the oil and placed on the in- 



502 DISEASES OF MAMMARY GLANDS AND LACTATION. 

cision the moment the first tin is removed. This guards against 
the possibility of mischief occurring during the cleansing of the 
skin with a dry cloth, and pressing out any discharge which may 
exist in the cavity. If a plug of lint was introduced when the 
abscess was opened, it is removed under cover of the rag, which 
is taken off the moment when the new tin is applied. The same 
process is continued daily until the sinus closes." 

In long-continued suppuration, methodical strapping of the 
breast with adhesive plaster, so as to afford steady support and 
compress the opposing surfaces, w T ill be best. The sinus may be 
laid open, or injected with tincture of iodine or other stimulant. 
Support the system with food, stimulants, iron and quinine, as 
indicated. 

PROF. F. CHURCHILL, M. D., DUBLIN. 

Bleed if the fever is high, or leech and follow with a large 
soft poultice or fomentation. A convenient and simple mode of 
applying warmth, is to immerse a wooden bowl in hot water, 
and having wrapped some flannel around the breast, place it in 
the bowl. Purge briskly with salines, to which add a little 
tartar emetic. The latter may be continued in doses of one- 
sixteenth grain every hour, to induce slight nausea, and generally 
in twenty-four hours the symptoms are mitigated, and the breasts 
smaller and softer. Diet bland and fluid. If an abscess is un- 
avoidable, favor it and open early. • 

J. S. PARRY, M. D., PHILADELPHIA, 

At the Philadelphia Hospital, urged the use of a fever mixture 
with ipecacuanha, or even tartar emetic, in a dose large enough to 
nauseate. This would be followed by relief of pain, fall of tem- 
perature and pulse. Where the subcutaneous areolar tissue is 
involved, iodine and astringent lotions are very useful. Put the 
iodine on freely, and then cover the breasts with cloths wet with 
acetate of lead lotion and opium. Give narcotics for pain and 



MASTITIS. 503 

sleep. Dr. P. believes that rubbing the breast is an irrational 
process, and that milk accumulated in the breasts is not injurious. 
It is not a cause of mastitis. He would delay opening the abscess 
when formed, and the popular idea that an abscess should " be 
ripe" before it is opened, is not entirely without foundation. He 
waits until the pus has approached the surface, and is almost 
ready to open spontaneously. 

Where sinuses form, carry a stick of nitrate of silver to the 
bottom, and leave it there, or inject iodine, sulphate of zinc, or 
copper. 

Q. C. SMITH, M. D., CALIFORNIA. 

345. R. Oleilini, f.-fiv. 

Chloral hydratis, J ss. M. 

Powder the chloral very fine, then mix it thoroughly with the 
oil. Apply, spread thickly, on a piece of soft woolen flannel, a 
little larger than necessary to cover the breast, with a central 
opening through which the nipple may protrude. 

Apply as xoarm as can be borne, and keep warm whilst it 
remains applied by warmed sacks of chamomile flowers or hops. 
The plaster should be renewed every four to six hours, until all 
pain, swelling and induration are relieved. {Pacific Medical 
Journal, May, 1878.) 

In acute mammitis, a number of observers have reported strik- 
ing success with the poke root : 

346. R . Fluidi extracti phytolaccse, q. s. 
Twenty drops every three hours. 

Others have seen benefit from : 



347. R . Tincturse belladonnse, 

Tincturse digitalis, aa f.^j. M. 

Ten drops every three or four hours. 



In chronic mammitis, Prof. Hunter McGuire, M. D., of 



504 DISEASES OF MAMMARY GLANDS AND LACTATION. 

Kichmond, Va., condemns ( Virginia Medical Monthly, Septem- 
ber, 1875,) the severe and needless practice of slitting up the 
sinuses, or of injecting them with stimulating fluids. Nearly 
every case can be cured by proper bandaging with adhesive 
plaster. 

Cut the plaster into strips from four to six inches in length, 
and from a half to three-quarters of an inch in width, according 
to the size of the breast. After warming the plaster, apply one 
end of a strip to the circumference of the gland, near the axilla. 
Take another strip of the same length and width, and fasten its 
end to the inner circumference of the breast, near the sternal 
bone. The ends of the two strips of plaster thus applied are 
held in place by an assistant, while the surgeon takes the free 
extremities of the strips, and drawing them toward each other, 
that is, drawing the breast from its circumference towards its 
centre, crosses the strips and fastens them. Two more strips are 
then applied just below, and lapping slightly the first two pieces. 
Continue in this way till the whole breast is covered (somewhat 
upon the same principle and manner that we use strips in an in- 
dolent sore on the leg), leaving the nipple and fistulous orifices 
uncovered. A piece of moistened lint is placed over the sinuses 
to catch the pus which escapes. 

ASHBURTON THOMPSON, M. D., LONDON, 

Speaking of mammitis (Medical Times and Gazette, January, 
1875,) mentions two modes of treatment, (1) the administration 
of tincture of aconite, and (2) the total abstention from fluids dur- 
ing the necessary number of days. By giving minim doses of 
aconite every hour, he had succeeded in cutting short inflamma- 
tions of the breast which there was no doubt would otherwise 
have run on to suppuration very frequently ; indeed, in three 
cases out of four. In cases of still-birth he had hitherto found 
abstention from fluids sufficient in every case to avoid every 
kind of mammary disturbance. Ice was allowed in moderate 
quantity, and no other fluid, from the time of delivery until the 



MASTITIS. 505 

fourth or fifth day, when the breasts generally return to their 
normal state of quiescence. The deprivation of fluid caused 
but little distress. 



JOHN B. C. GAZZO, M. D., THIBODAUX, LA., 

In Med. and Sur. Reporter, May 6th, 1876, gives his treatment 
as light diet, alteratives, and tonics, a compress moistened with 
the linimentum ammonise iodidi et chloroformi applied to the 
breast as high as the axillae, carefully enveloping the diseased 
mammae, covering the compress with oiled silk, and keeping the 
whole in a suspensory bandage ; during the first day renew the 
application once in two or three hours. This proceeding must 
be repeated every day until the swelling disappears, which is, 
usually, the second or third day. The liniment of chloroform 
and iodide of ammonia should be applied the moment that pain 
and engorgement of the mammary glands manifest themselves ; 
it will then act as an abortive in suppressing incipient pain, and 
thereby prevent the inflammation which threatens the mammary 
structure. The inflammatory period of the mammary is not 
only shortened, but the entire duration of the disease is dimin- 
ished by at least one-half. After the large, heavy and inflamed 
mamrase become perfectly flaccid, completely cool, and the flow 
of milk begins anew, allowing of the freest handling, omit the 
application. The only inconvenience attending it is the irrita- 
tion produced upon the skin ; this, however, is more than com- 
pensated for by the derivative action of the iodide of ammonia 
and chloroform upon the inflamed breast, which will very often, 
in all probability, prevent abscess and suppuration. 

In addition to appropriate medical remedies, the following 
prescriptions were employed with the happiest results ; the first, 
an excellent detergent and purifier of the blood, preventing the 
formation of matter within the glandular system ; and the 
second, a tonic in restoring the mucous membranes : 



506 DISEASES OF MAMMARY GLANDS AND LACTATION. 

348. R . Potassii chlorat., 
Aquse destil., 
Acidi. hydrochlorici, 

Syrupi aurantii, £j|iij. M. 

SiG. — One tablespoonful every two hours. 



3u- 

f.gvilj. 
gtt. XXX. 


f-ifiij. 





349. R. Cinchonse sulph., 

Quiniae et ferri citras., 
Tinct. ferri chloridi, 

Syrupi sennas, f-.l v y- M. 

SiG. — One tablespoonful three times a day, after diet or meals. 

The liniment of iodide of ammonia is prepared as follows : 

350. R. Iodinii, > _ giij. 

Ammoniae iodidi, gij. 

Chloroformi 

01 ei olivse, aa f-fx. 

Glycerinae, i.% v. 

Dissolve the first two by rubbing in the chloroform ; then add the olive 
oil and glycerine. 



C. B. KEIPER, M. D., INDIANA. 

The first fifteen years of practice he used belladonna poul- 
tices, and so forth. Now and then he would have a suppurating 
breast ; and in cases that did not suppurate, it would require 
from six to ten days to subdue the inflammation. 

In the last fifteen years he made no other applications than 
cold water and muriate of ammonia; two ounces of muriate of 
ammonia to a half gallon of cool water. Where ice cannot be 
had, put the solution in a tin bucket, and place this bucket in 
another one of cool water, so as to keep it at a low temperature 
(in city practice ice may be employed) ; then take two pieces of 
cotton goods, each about twenty inches square, and double each 
one four times, and then cut a hole in the centre about two 
inches in diameter, so as to protect the nipple, and dip these in 
the solution, and apply to the parts affected ; removing every 
twenty minutes, to immerse anew in the solution. This continue 
till the inflammation is subdued, which generally requires from 
one to three days. 



MASTITIS. 507 

HUGH MILLEE, M. D., OF GLASGOW. 

In cases where acute congestion occurs in the mammary 
glands when commencing to secrete, this author [Edinburgh 
Med. Journal, December, 1877,) employs, with great success, a 
preparation of belladonna. It is an alcoholic extract of double 
the usual strength, kept fluid by collodion. Camphor is com- 
bined with it for the purpose of aiding to arrest the natural 
mammary secretion. This preparation is painted on the breasts 
much in the same way that you would use blistering fluid. No 
rubbing in is necessary. The fluid dries quickly, is much more 
cleanly for the patient, has a less offensive odor than the oint- 
ment, and in his experience, it is more reliable in its action. 

This liquid preparation is painted over the affected parts of 
the breast night and morning, until the acute symptoms give 
in. Indeed, it can only be of service as a good local sedative 
when the free and frequent application of it to the affected part 
has been persevered in until decided results are secured. He 
has used this preparation with very satisfactory results. Whether 
the inflammatory irritation accompanying the onset of the lacteal 
secretion had for its exciting cause exposure to cold, inflamed 
nipples, or obstruction in the lacteal ducts, the preparation has 
always seemed to be of value. He has also used the preparation 
beneficially by applying it to both breasts every day when the 
mother did not intend to suckle her child ; and is satisfied that 
it may be safely relied upon for restraining the secretion of 
milk, and acting on the walls of the arterioles so as to prevent 
engorgement. It has the advantage over the old plan of 
evaporating lotions, in that it is more cleanly, and is more com- 
fortable to the patient. When the remedy is employed to pre- 
vent the secretion of milk forming at all, it is best to begin 
applying the liquid immediately after the birth of the child. 

EDGAE KUEZ, M. D., TUBINGEN". 

In the lyinjr-in hospital at Tubingen, this author treated the 
very frequent cases of commencing mastitis in the following 



508 DISEASES OF MAMMARY GLANDS AND LACTATION. 

manner : "When the breast is tense with milk and becomes hard 
and sensitive, it frequently suffices merely to restrict the diet of 
the patient, and to remove the superabundant milk by nursing 
several children, or drawing it out with one of the various appli- 
ances devised for the purpose, or by gently expressing it. When 
the affection has advanced a step farther, and the breast is much 
swollen and lumpy, and the skin reddened, and suppuration ap- 
pears imminent, it is necessary to adopt energetic measures. The 
diet is still more restricted, laxatives are given, the breast is 
securely bound up by a cloth, without, however, exerting com- 
pression, which is suitable only for chronic cases, or the residual 
nodosity following acute mastitis. The main point of the treat- 
ment is the application of cold, which in light cases consists 
merely in iced compresses ; in severe cases in the unremitting 
application of a bladder filled with ice. The often intolerable 
pain, which is increased by compression, yields rapidly to this 
treatment ; the tension decreases, suppuration is prevented, and 
in a few days even mastitis may be cut short in this manner. 
During two years of this treatment, not one case of mastitis ter- 
minated in suppuration, whilst under compression it frequently 
occurred. 

PROF. F. WINCKEL, M. D., 

Applies dry heat if very acute pain persists after the use of com- 
presses of cotton batting, cold compresses, or the ice-bag. When 
headache is severe and the tongue coated, he gives large doses of 
iodide of potassium. To reduce the thickness of the skin and 
expedite the evacuation of pus, he paints with iodine. Evacuate 
pus promptly. 

When a portion of the gland is tender, swollen, and the sur- 
face red, give the breast as much rest as possible, by less frequent 
nursings, or entire cessation on that side. Use compresses, wet 
with lead-water, night and day, renewing them every few min- 
utes, supporting the breast. Keep the bowels free. Continue 
until the nodules disappear, or alternate the lead with tincture 
of iodine, if there is reason to believe that an abscess is forming. 



MASTITIS. 509 

Pointing of pus is thus hastened. A plaster of Paris bandage 
applied to the breast is excellent after evacuation of pus, as it 
insures uniform compression of the gland. Change it every two 
or three days. Other methods have been employed, but this 
should completely supersede the use of warm poultices. 

To remove any lacteal nodes, mercurial ointment or iodide of 
potassium may be rubbed on, or the parts covered with emplast. 
saponis., emplast. cicutse, or emplast. melliloti, and iodine, given 
internally, the child having been weaned. 

J. L. POWEKS, M. D., IOWA. 

This writer, in the Medical Brief, October, 1878, uses tobacco 
salve spread upon drilling, the size of the breast, with a hole in 
the centre for the nipple. 

Internally, when inflammatory symptoms are marked : 

351. R. Spt. ether, nit., f.^ss. 

Tr. veratri virid., f. £ ss. 

Aquee, £3 iij. M. 

Teaspoonful every hour or two, until it produces a sedative effect, and then 
less frequently. 

With concentrated tincture of phytolacca, 15 to 20 drops, and 
this used persistently, he believes an abscess may be avoided. 

KESUME OF EEMEDIES. 

Acetum. The application of a cloth wrung out in hot vinegar, 
which is then covered with a bowl moderately heated, 
is a popular means of aborting threatened inflammation 
of the breasts. 

Aconitum, in minim doses of the tincture, is recommended by 
Dr. Thompson. (P. 504.) 

Ammonii Murias, as a resolvent local application, has been found 
very efficient. (P. 506.) 

^Belladonna. In recent induration and inflammation of the 
breasts, remarkable effects are produced by belladonna 
in arresting the secretion of milk. Either as plaster or 
ointment, or also internally, its use should not be 
omitted. 



510 DISEASES OF MAMMARY GLANDS AND LACTATION. 

Chloral is applied locally by Dr. Q. C. Smith. (F. 346.) 
Chlorofomium. Dr. S. W. Gould, of Indiana, states in the 
Med. and Surg. Reporter, August 10th, 1878, that in 
acute mammitis he has for ten years used the following 
without having occasion to lance a single breast : 



352. R. Chloroformi, 

Glycerinse, aa equal parts. M. 

Shake thoroughly, apply quickly every hour, and. cover with oiled silk. 



Conium. In chronic engorgement or hyperplasia of the breasts, 
the prolonged use of conium internally has a decided 
influence in reducing the size. 

Digitalis, in inflammatory states, may sometimes be advantageously 
combined with belladonna. (F. 344.) 

Ergota moderates the secretion of milk, and has been used to 
prevent mammary abscess and engorgement of the 
breasts during weaning. 

Jodinii Tinctura, in the chronic forms of engorgement, is a val- 
uable resolvent. 

Petroselinum. Freshly bruised parsley leaves are a popular rem- 
edy in commencing mammary inflammation at the be- 
ginning of lactation. 

^Phytolacca Decandra is known popularly as the "garget 
weed," and is extensively used for garget (mammary 
inflammation) in cows. Considerable evidence has 
been adduced that it possesses equal value in the human 
female. It is given in doses of gtt. xx. of the fluid 
extract of the root every three or four hours. (Am. 
Jour. Med. Sciences, 1873, p. 275; Med. and Surg. 
Reporter, January, 1875.) Dr. J. G. Allen states 
(Am. Jour. Obstetrics, October, 1879,) that it is not of 
value where the mammitis begins at the nipple or only 
involves small lobes of the gland ; but where the whole 
or a large portion is swollen and congested, and in the 
condition of congestion that sometimes results from an 
attack of ephemeral fever, the phytolacca is almost a 
specific. 

Plumbi Acetas. Dr. Huebner, of Dresden, recommends the 
constant application of lukewarm lead- water in com- 



MASTITIS. 511 

presses, followed, if required, by strapping of the 
breast and free incision. 

Plumbi Iodidum. The discutient powers of this agent may be 
advantageously called into play in chronic engorgement 
of the mammary glands. 

Stramonium. The fresh leaves of stramonium, made into a cata- 
plasm and applied externally, have been found success- 
ful for discussing indurated lacteal glands in the breasts 
of nurses. (Phillips.) 

Tabacum, in the form of ointment, gr. xxx. to lard I j., has long 
been used in some parts of this country as a domestic 
application to inflamed and " caked " breasts. 

GENERAL MEASURES. 

Cold. Some writers are very positive in praise of cold applica- 
tions in threatened inflammation of the mammary 
gland. Pounded ice is placed in a bag and laid di- 
rectly upon the gland, to be renewed from time to time. 
The pain and swelling are said to abate promptly, 
" within an hour," and in a few days the inflammatory 
action has quite disappeared. (See p. 508.) 

Compression is highly praised by most authorities. (See pp. 506, 
507, 508, 509.) Dr. Koenlng says that in mammary 
lymphangitis it is " infallible." The method which he 
employs [London Med. Record, April, 1877,) is the 
following : The diseased breast is covered with a layer 
of cotton-wool, and a bandage is applied which is 
known in minor surgery as the bandage of Mayor, or 
the triangular bonnet of the breast. The form of the 
bandage is a triangle, a yard in length from one ex- 
tremity to the other, and fifty centimetres (nearly 
twenty inches) from the apex to the base. The base 
of the triangle is placed obliquely under the diseased 
breast, then one of its extremities is directed under the 
corresponding armpit, and the other over the opposite 
shoulder, and there united behind the shoulder-blade. 
The apex of the triangle is then lifted in front of the 
diseased breast, it is carried over the corresponding 
shoulder, and firmly fixed behind. 

Sometimes a linseed poultice is at the same time ap- 
plied on the inflamed part. 



512 DISEASES OF MAMMARY GLANDS AND LACTATION. 

The effects of treatment thus arranged are almost 
marvelous; the pain is immediately calmed, the in- 
flammatory redness, and the oedema are diminished at 
the end of a very short time. 
Heat is more popular than cold as a means to effect resolution. 
Hot vinegar, lead-water, etc., warm poultices, heated 
bowls or plates, etc., are familiar applications, and 
often successful. 



MAMMARY TUMORS. 



513 



MAMMARY TUMORS. 



DIAGNOSTIC POINTS. 



The diagnosis of mammary tumors is confessedly difficult. 
We give from various surgical authorities a few points to serve 
as diagnostic landmarks. 

1 . The tumor presents itself as a small nodule in the breast. 

It may be merely a benign chronic mammary tumor (adenoma), 
or the beginning of sarcoma, or scirrhus. 



Adenoma. 

Patient under thirty and 
single. 

Tumor dense, but elastic 
and movable under the 
skin, and movable on 
the deeper part of the 
breast. 

Pain, if present, of a neu- 
ralgic character, and 
worse at the menstrual 
period. 

Skin and lymphatics 
never involved. 



Grows very slowly, 

varies in size. 
Nipple not retracted. 

No family history. 



and 



Sarcoma. 
Patient any age. 

Tumor elastic and mov- 
able, but rapidly in- 
volving the surround- 
ing tissues. 

Pain not severe as a rule. 



Skin eventually involved 
but no lymphatic en- 
largement. 

Grows very rapidly, and 
apt to recur locally. 

Nipple often exudes 
fluid. 

No family history. 



Scirrhus. 
Patient over thirty. 

Tumor hard, and at- 
tached to the deeper 
part of the breast, 
though at first mova- 
ble beneath the skin. 

Pain severe, and of a 
sharp, lacerating char- 
acter, and shooting 
down the arm. 

Both skin and lymphat- 
ics involved early. 

Grows rapidly, except in 

old people. 
Nipple often retracted. 

Often hereditary. 



Of these signs, the enlargement of the lymphatic glands of 
the axilla and the neck is the most important point in the 
.diagnosis of scirrhus. 

Adenoma generally occurs in the breasts of young, healthy 
women, during their period of developmental perfection. 
Among married women it often occurs among those who are 
suckling. It usually grows slowly, and as it enlarges, pushes 
the breast aside ; it never infiltrates it. It may grow to a great 

33 



514 DISEASES OF MAMMARY GLANDS AND LACTATION. 

size, and stretch the skin even to the point of rupture ; but the 
skin is never infiltrated, nor the tissues beneath. The tumor is 
encapsuled, and usually movable, and can be readily turned out. 
It is never associated with any secondary glandular enlarge- 
ment. 

2. The tumor is elastic. 

Its contents should be drawn to the extent of a drop or two 
by a needle, and examined. If the fluid proves to be : 

(a) Pus, the case is one of abscess. 

(b) Milky fluid, it is galactocele. 

(c) Clear fluid, it is simply cyst. 

(d) Dark fluid, it is compound cyst or sarcomatous cyst. 

(e) Clear fluid containing microscopic hooklets, it is hydatid. 

3. The tumor is laxge, elastic, and rapidly growing. 
It may be : 



Encephaloid Cancer, 
No cysts present. 
Lymphatic enlargement in the axilla 

and neck. 
Skin infiltrated and thickened, often 

with small flattened nodules. Veins 

enlarged. 



Benign Cystic Growth. 
Cysts present. 
No lymphatic enlargement. 

Skin stretched and thin, so as event- 
ually to give way. Veins about 
natural. 



Hysterical Breast. This is a rather rare affection. Its inva- 
sion is often sudden, and the malady rapidly reaches its maxi- 
mum of intensity. It is ushered in by a sense of uneasiness 
and formication, which is soon transformed into lancinating 
pains, becoming almost intolerable. In some cases the skin is 
changed, in others it becomes red, hot and swollen, and remains 
so till the end of the exacerbation. In the meanwhile, the 
gland enlarges to an enormous size. The ovaries are sometimes 
in sympathy. This condition lasts from one to three days. These 
troubles generally coincide with the period of menstruation or 
an hysterical attack. 

The breast is subject to various other forms of tumors, some 
of which are dependent upon disorders of the secretion, and 
others on inflammation and its results. As the distinction between 



MAMMARY TUMORS. 515 

these is difficult, and yet of great importance in practice, we 
quote on the two following pages a comprehensive table of the 
differential diagnostic symptoms, as arranged by Dr. D. S. 
Adams, in the Transactions of the Medical Society of the State of 
New Hampshire } 1879 : 



516 DISEASE OF MAMMARY GLANDS AND LACTATION. 



Galactocele. 



Congestion vrith Milk. Chronic Enc't Abe's 



1. During the child- 
bearing period, and 
the result of pregnan- 
cy- 

2 No pain. 



3. System not dis- 
turbed. 

4 Breast consider- 
ably enlarged. 

5. Local circulation 
active in both breasts. 

6. Tumor quite a 
size, but if it has been 
in the breast long it 
is not as large as it 
was, on account of the 
more fluid portion 
being absorbed ; but 
harder. 

7. May give an elas- 
tic feel, or fluctuation, 
or may be hard. 

8. Single. 

9. Nipple may or 
may not be connected 
with the tumor. If a 
simple dilation has 
taken place, it is con- 
nected ; if a rupture, 
it may not be. 

10. Freely movable. 

11. Skin disturbed 
over it. 



12. Growth rapid; 
tumor fills every time 
the child nurses, then 
gradually subsides 

13. Nipple never re- 
tracted. 

14. Surrounding 
glands never impli 
cated. 

15. Superficial veins 
enlarge in both the 
breasts. 

16. Puncture. — 
Cheesy mass or cream 

17. Microscope, 
Milk or fat globules, 
Avith more or less epi 
theiial cells undergo- 
ing fatty degenera- 
tion. 



1. During the child- 
bearing period, and 
the result of preg- 
nancy. 

2. Some dull pain 
sometimes ; not com. 
mon. 

. System consider- 
ably disturbed. 

4. Breast very much 
enlarged. 

5. Local circulation 
active in both breasts. 

Tumor large and 
lobulated. 



Stony hard. 



i. Single. 



1. During the child- 
bearing period usu- 
ally, and most com- 
monly the result of 
pregnancy. 

2. No. pain. 



3. A System not dis- 
turbed. 

4. Breast not much 
enlarged. 

5. Local circulation 
some increased in 
both breasts. 

6. Usually small 
and irregular in 
shape. 



7. May give an elas- 
t i c feel, otherwise 
hard. 

8. Single. 



Adenoma. 



9. Nipple always 9. Nipple may or 
connected with tu- may not be connect- 
ed with the tumor ; 
usually is. 



10. Not freely mov- 
able. 

11. Skin disturbed 
over it. 



12. Growth rapid to 
a certain size, then 
stationary. 

13. Nipple usually 
retracted or imbed- 
ed in the breast- 

14. Surrounding 
glands never impli- 
cated; but may be 
some swollen. 

15. superficial veins 
enlarge in both 
breasts. 

16. P u n ct u re. — 
Cheesy mass or cream 

17. Microscope. — 
The same as in galac- 
tocele. 



10. Not freely mov- 
able. 

11. More or less 
oedema of the areola. 



12. Growth slow. 



13. Nipple usually 
flattenedor retracted. 

14. Surrounding 
glands may be some 
swollen. 

15. Superficial veins 
may or may not be 
enlarged. 

16 Puncture —Pus. 

17. Microscope. — 
Pus corpuscles. 



1. Majority of cases 
under the age of 30, 



2. If painful, pain 
dull and most severe 
at catamenial period. 

3. System not much 
disturbed. 

4. Breast slightly 
enlarged. 

5. Local circulation 
some increased in the 
breast affected. 

6. Tumor small and 
nodulated 



7. Moderately hard. 



8. May be single or 
multiple. 

9. Nipple always 
connected with tu- 
mor. 



10. Freely movable. 

11. Skin normal, 
unless the tumor has 
reached considerable 
size, when it be- 
comes stretched over 
the tumor. 

12. Growth slow 
under the age of 30 ; 
after that, rapid. 

13. Nipple projects. 



14 Surround ing 
glands never impli- 
cated. 

15 Superficial veins 
usually enlarged. 

16. Puncture. — 
Solid. 

1 7. Microscope. — 
Epithelial cells if 
taken from the in- 
terior of the acini; 
otherwise, may get 
connective issue. 



MAOIARY TUMORS. 



517 



Soft Carcinoma. 



1. Very rare under 
the age of 30. 

2. May or may not 
be painful. Is not 
usually painful till 
skin is implicated ; 
then pain severe and 
cutting, running to 
the shoulder and 
down the arm. 

3. System consider- 
ably disturbed. 

4. Breast some en- 
larged, and enlarges 
rapidly. 

5. Local circulation 
some increased in the 
breast affected. 

6. Tumor quite a 
size, irregular, and 
not well denned. 

7. Usually soft, with 
a doughy feel. 



8. Single, but lobu- 
lated feel — may give 
the feel of a multiple 
tumor ; but you can- 
not roll one on the 
other. 

9. Nipple always 
connected with tu- 
mor. 

10. Freely movable 
at first. Soon adhe- 
rent. 

11 Skin normal at 
first, but becomes im- 
plicated early. 

12. Growth rapid. 



13. Nipple projects 
at first, but soon be- 
comes retracted. 

14. Surrounding 
glands soon implicat- 
ed as the growth is 
rapid . 

15. Superficial veins 
enlarged early. 

16. Punctuie.— Tu- 
mor soft, but no dis- 
charge. 

17. Microscope. — 
Epithelial cells ar- 
ranged in alveoli, 
with no connective 
tissue separating the 
cells. The alveoli 
separated by well- 
marked connective 
tissue bundles. 



Hard Carcinoma. 



1. Very rare under 
the age of 30. 



Sarcoma. 



1. Majority in pa- 
tients over 30. 



2. Usually not pain- 2. Mayor may not 
ful till skin is impli- be painful, 
cated; then pain se 
vere and cutting, or 
stabbing, running up 
to the shoulder and 
down the arm. 



3. System not much 
disturbed. 

4. Breast normal at 
first. 

5. Local circulation 
apparently normal. 

6. Tumor small and 
smooth or nodulated. 

7. Tumor hard. 



8. Single. 



9. Nipple always 
connected with tu- 
mor. 

10. Freely movable 
at first. 

11. Skin normal till 
late in disease. 

12. Growth slow. 



13. Nipple normal 
at first ; may or may 
not be retracted later. 

14. Surrounding 
glands not implicated 
till late in disease. 



3. System usually 
disturbed some. 

4. Breast slightly 
enlarged. 

5. Local circulation 
slightly increased in 
breast affected. 

6. Tumor quite a 
size, and irregular. 

7. Tumor a little 
soft. 



8. Usually single. 



9. Nipple may or 
may not be connected 
with tumor. 

10. Not freely mov- 
able. 

11. Skin normal. 



12. Growth slow, 
and may remain 
small for years, then 
grow very rapidly. 
May have a vegeta- 
tion spring from its 
wall forming the 
compound cyst. 

13. Nipple may or 
may not" be retracted, may not be retracted ; 

lis not usually. 
14. Surrounding) 14. Surrounding 
glands never impli- glands never impli- 
cated, j cated. 

15. Superficial veins 15. Superficial veins' 15. Superficial veins 
not enlarged till late may or may not be may or may not be 



12. Growth usually 
rapid. 



13. Nipple may or 



Primary Cyst. 



1. At any age above 
puberty . Majority 
under 30. 

2. Not painful usu- 
ally. 



3. System not dis- 
turbed. 

4. Breast appears 
normal. 

5. Local circulation 
normal. 

6. Tumor small and 
may be nodulated. 

7. May give an elas- 
tic feel ; otherwise, 
hard, and may be 
finely nodulated. 

8. Frequently mul- 
tiple ; and when so, 
can readily roll one 
tumor on the other. 



9. Nipple may or 
may not be connected 
with tumor. 

10. But little mov- 
able when deep-seat- 
ed. 

11. Skin normal. 



in disease. 

16. Puncture.— Sol- 
id. 



enlarged. 

16. Puncture. 
id. 



-Sol- 



17. Microscope. — 17. Microscope 
The same as soft, ex- Spindle shaped cells 
cept more connective are characteristic. If 
tissue and less cells, it be round-celled, the 
The arrangement of.cells resemble epith- 
cells the same. Theelial cells, but are not 
cells may break down so distinctly arranged 
so as to leave smallin alveoli, and have 
granules in the alve- connective tissue run- 
oli. In this case the ,ning all through be- 
epithelial character is t ween the cells, 
lost. I 



enlarged. 

16. Puncture . — 
Fluid. 

17. Microscope. — 
If primary, the walls 
are simple connective 
tissue If secondary, 
the walls same char- 
acter as tumor from 
which it was formed. 



518 DISEASES OF MAMMARY GLANDS AND LACTATION. 
PROF. SAMUEL D. GROSS, M. D., PHILADELPHIA, 

Considers the great object of the constitutional treatment in 
carcinoma, as the maintenance of the general health as near the 
normal as possible, and the best means are a proper regulation 
of the diet, bowels and secretions, the avoidance of pain, plenty 
of sleep, and a contented mind. The diet should be that which 
agrees with the stomach, and affords the best nourishment in the 

O 7 

smallest compass. The plethoric should have farinaceous food 
principally, while the anaemic require meat, and even malt 
liquors or stimulants. 

Pain may be allayed by anodynes in suitable doses. A hot, 
dry skin requires pulvis ipecacuhanse comp. and a few grains 
of blue mass ; change of air and scene, as to the sea-coast, are 
often beneficial. Specifics fail to cure, though they often im- 
prove the health. Of these we have quinine, bark and iron, as 
the best. Arsenic is useful, and the best form is the iodide, one- 
sixteenth of a grain three times a day. 

The topical treatment should be suspension of the organ, and 
the removal of all pressure. Leeches may be applied when there 
is inordinate vascular excitement, especially if the patient is ple- 
thoric, and the flow of blood may be encouraged for some hours 
by cloths wrung out of hot water. Afterwards the parts may 
be kept wet with lotion of acetate of lead and opium. Light 
emollient poultices are useful, and may be medicated with lead, 
opium, dilute tincture of iodine, etc. Anodyne plasters of opium, 
cicuta, stramonium and belladonna, are comforting. The soap, 
compound galbanum and De Vigo's plaster, are useful if well 
sprinkled with morphia. 

When ulceration occurs, the indications are to moderate dis- 
charge, prevent hemorrhage, relieve pain, allay fever, and sus- 
tain the strength. Here we may use subsulphate of iron, 
anodynes, Labarraque's solution, or permanganate of potassa, 
frequent ablutions and good diet, with stimulants. If there is 
copious hemorrhage, acupressure may be employed. 

Excessive swelling of the arm may be relieved by the roller 



MAMMARY TUMORS. 519 

bandage and steady elevation of the limb. [The strong elastic 
bandage will in these cases be found of very great value. — Ed.] 

Itching of the skin maybe relieved by zinc ointment and 
Goulard's extract. 

Mammary hypertrophy may be met by iodine, externally and 
internally ; gentle and protracted ptyalism; the steady and per- 
sistent exhibition of chloride of ammonia, 10 to 20 grains three 
times a day ; the relief of weight and- tension. Extirpation 
must be employed if the tumor is large and the health is 
failing. 

Milk tumors should be injected with a stimulant, as dilute 
tincture of iodine, and the seton or tent may be employed, with 
care that the inflammation does not run too high. When the 
tumor is solid, it may be excised. 

[We have seen a number of such tumors, and have invariably 
advised non-interference, and have never known bad results to 
follow.— Ed.] 

Serous cysts will sometimes disappear under the steady use of 
discutients, as a strong solution of chloride of ammonia, or equal 
parts of alcohol and spirit of camphor, with a small quantity of 
Goulard's extract. Or a cure may be effected by the seton, tent, 
or iodine injections. When the cyst is old, large, or partially 
solidified, excision is necessary. 

The only remedy for hydatid tumors is excision. Relapse 
does not occur. 

For fibroid and adenoid tumors, sorbefacients and compression, 
with iodine internally, may be tried in the earlier stages; after- 
wards excision is the only reliable means. 



In small, circumscribed, mobile growths, methodical compres- 
sion with pads of agaric or an air cushion holds out some hopes 

* Treatsie on Tumors of the Mammary Gland, 1880 



520 DISEASES OF MAMMARY GLANDS AND LACTATION. 

of success. The inunction of stimulating ointments is not only 
useless but liable to prove irritating. 

Dr. Gross considers the knife the best measure in all mam- 
mary malignant growths, and the earlier the better. Caustic ap- 
plications are uncertain and painful. He would restrict their 
employment to the allaying of fcetor and the improvement of the 
surface of open cancers. In cases of this description he com- 
mends Esmarch's powder : 

353. R . Acidi arseniosi, 

Morphias muriatis, aa 0.25. 

Hydrargyri chloridi mitis, 2.0. 

Pulv. acacias, 12.0. M. 

Of this, half a teaspoonful is to be sprinkled daily on the sur- 
face until a yellowish and leathery crust is formed, which on 
dropping off leaves a clean, granulating surface. This applica- 
tion is safe, painless and disinfecting, and its good effects are 
often striking. The paste of chloride of zinc, as usually em- 
ployed, is excessively painful. 

When operative interference is inappropriate, the most that 
that can be done is to render life endurable by relieving pain, 
arresting hemmorrhage and diminishing fcetor. 

To relieve pain, hypodermic injections of morphia combined 
with a minute quantity of atropia should be used. When the 
pain is increased by the rapid growth of the tumor, nothing 
mitigates it so rapidly as : 

354. R . Plumbi acetatis, gr. xv 

Aquas, j|j. M. 

For a local application. 

When the breast is hot, tense and tender, ice-bags give great 
relief. When the active symptoms have subsided, these meas- 
ures may give way to the following application : 

355. R • Extracti belladonnas, 

Extracti stramonii, aa 5jj. 

Extracti petrolei, ^j. M. 



MAMMARY TUMORS. 521 

When hemorrhage resists cold and the ordinary applications, it 
may be checked by pressing upon the part a bit of cotton which 
has been soaked in Hon sell's solution and dried. 

As a deodorizer, the following, which also possesses the merit 
of assuaging pain, will be found useful • 

356. R . Chlorali hydrat, gr. v 

Unguenti petrolei, Jj. M. 

This is also an excellent remedy after dead parts have sloughed 
away. 

Sloughing tumors should be covered with a slippery-elm poul- 
tice medicated with balsam of Peru, permanganate of potassa, 
chloral u in or girondin. 

PROF. JAMES Y. SIMPSON, M. D., EDINBURGH, 

In speaking of carcinoma of the mamma, says the two serious 
objections to the knife are, the probability of a relapse, and the 
danger of the operation. Hence the treatment by caustics re- 
quires to be considered ; these give less pain, and the wound 
heals more readily than that left by the knife. Nor is the result 
less complete, as " there is good reason to believe that the modi- 
fying influence of the caustic probably sometimes extends also 
to cells and structures which may be wholly, or only in part, 
affected and morbidly altered and which lie beyond the line of 
immediate extirpation." Caustics may be applied to all forms 
of cancer. The remedies from which the best have been ob- 
tained, are the chloride of zinc used in the form of a paste with 
starch or flour, the pernitrate of mercury and the sulphate of zinc. 
The latter, when dried and powdered, is a very powerful caustic. 
Prof. Simpson" applied it in several cases with complete success. 
To apply it to the base, or into the interior of a tumor, it may be 
mixed with sulphuric acid. 

The greatest advance in this treatment has been in the more 
clear and practical views as to the mode of using the caustics, 



522 DISEASES OF MAMMARY GLANDS AND LACTATION. 

their introduction into the centre or the base, so as to produce 
quickly mortification of the entire mass. With the sulphate of 
zinc, an ordinary quill pen may be used. Saturate strong sul- 
phuric acid with the zinc dried and powdered ; dip the pen into 
it, and lay the caustic in a number of lines across the tumor. 
Soon the skin is killed in the course of these lines ; then scratch 
the filled pen along these lines, and the skin is readily cut 
through. Fill the fissures with the paste, and every day or two 
renew it, thus cutting down. In the first application, he usually 
made a fissure of a fourth or three-eighths of an inch in depth. 
Thus, in five or six days, a good-sized tumor may be removed. 
Dress with black wash, chloride of zinc, sulphate of zinc, or 
nitrate of silver. The healthy skin at the edge of the mass 
usually granulates, and is partially cicatrized before the dead 
tumor is separated. 

Maisonneuve, of Paris, recommends " caustic arrows ;" these 
are pieces of paste of chloride of zinc, in the form of small cones, 
sharpened to facilitate their entrance into the mass. He usually 
punctures the tumor all around, and introduces an arrow deeply 
into each wound. Or, he introduces, parallel to each other, a 
number of flattened pieces of the paste. 

Perhaps, as these cause severe hemorrhage, arrows of chloride 
of zinc and perchloride of iron might answer better. 

The injection of a sulphate of zinc lotion, or of some other 
equally powerful caustic, by means of a small syringe, has been 
tried, but not with the best results as yet. Perhaps, if a larger 
tube were used, and such articles as the perchloride of iron 
thrown by one opening, but at different angles, into the mass, 
more beneficial results might be obtained. 



MAMMARY NEURALGIA. 523 



MAMMARY NEURALGIA (MASTODYNIA.) 

Occasionally during lactation, the mammae are the seat of in- 
tense neuralgia, compelling the woman to abandon nursing unless 
relieved. For this condition Dr. Fordyce Barker has found 
quinine in full doses twice a day an efficient remedy. 

It is not uncommon in the early months of pregnancy, and also 
in non-pregnant women of a hysterical constitution, to find in- 
stances of neuralgic pain in the mammas. In most of these 
cases, narcotic fomentations, and opium internally, will give 
relief. Occasionally the hypodermic use of morphia will be 
requisite. 

Tanner speaks well of the valerianate of iron or of zinc ; and 
also the tincture of actea racemosa, combined with small doses 
of aconite where there are signs of engorgement. Cod-liver oil 
has relieved some cases which have resisted all other remedies. 
He has found quinine chiefly serviceable where some degree of 
periodicity is manifest. Mental relief will always be given by 
calming the patient's fears as to the nature of the disease, since 
directly a nervous woman has pain in the breast, she usually con- 
cludes it must be due to cancer. 

Dr. Anstie says that in some cases, discontinuance of nursing 
has been found necessary, but generally, complete rest, protection 
of the breast from air and friction, and the hypodermic injection 
of morphia will rapidly relieve. Very frequently it is the result 
of malnutrition, and is then readily and permanently cured by 
an abundance of easily digested, nutritious food. As medica- 
ments, we may use the tincture of chloride of iron in full doses, 
and still better, combine it with strychnia, 10 minims of the 
iron to ^o grain of the strychnia. Arsenic, phosphorus, and 
belladonna have each proved extremely useful. 



524 DISEASES OF MAHMAKY GLANDS AND LACTATION. 



GALACTORRHEA. 

An excessive flow of milk, while very exhausting to the wo- 
man, is exceedingly liable to cause positive and permanent ill 
health. Many authors relate cases of insanity which were un- 
doubtedly due to an excessive flow of milk inducing ansernia ; 
and the anxiety of the mother to nurse her child, fearing that 
her increasing weakness would incapacitate her, has culminated 
in mania, perhaps causing her to take the life of her offspring. 
The milk itself is apt to be thin and watery, deficient in the 
vital constituents. The treatment will consist in the generous 
support of the woman by appropriate food, avoidance of fluids, 
and the use of astringent tonics. If not readily checked, and 
the general health shows indications of being affected, lactation 
may be partially or wholly suspended. Coffee is regarded by 
some authorities as capable of suppressing the supply of milk. 
The editor has used it for this purpose, but as this was associated 
with other remedies, he is unable to give its true value. 

DE. L. DE SINETY. 

The general rules are to wean the child ; to administer tonics 
and iron if the patient is anaemic ; and to endeavor to recall the 
menses by warm, sinapized foot-baths, leeches to the vulva, etc. 

Narcotics, as opium internally, or friction with liniments con- 
taining morphia, have some success. So also have compresses 
wet with muriate of ammonia and iodide of potash. 

357. R. Ammonise muriatis, ^iiss.-v. 

Potassii iodidi. giij. 

Aqua?, f.| v i. M. 
For local use. 

Internally a combination of white agaric with the iodide gives 
encouraging results : 



GALACTORRHEA. 525 

35S. K. Agarici, gr. iv. 

Potassii iodidi, gr. ij. M. 

For one capsule, four or six times a day. 

But the best curative procedure is systematic compression. 
The mammae should be thickly covered with wadding so as to 
make a large, elastic cushion. Upon this, broad strips of adhe- 
sive plaster should be applied, passing under the arm-pit and 
quite around the body. It should then be crossed upon the 
breast sufficiently to compress firmly without too severely press- 
ing the gland. If adhesive plaster cannot be used on account 
of the sensitiveness of the skin, ordinary rollers may be substi- 
tuted. 

PROF. WM. LEISHMAN, M. D., GLASGOW, 

Says the quantity alone may be abnormal, and only requires in- 
terference to guard the health of the mother from the unneces- 
sary drain. This requires regulation of the woman's diet. Or 
in addition to the excessive quantity, the bulk may be mainly of 
water, thus affecting the health of child and mother. As this is 
believed to be associated with a phthisical tendency, it would be 
better to wean the child. 



This author considers the treatment as both dietetic and medi- 
cinal. If the woman have suffered from menorrhagia, or other 
habitual discharge, and is not weak, purgatives and other deriva- 
tives may be used, the breast kept cool, and the child not applied 
more frequently than every three hours. It is, however, gene- 
rally the result of weakness ; hence tonics are required, especially 
those of an astringent character, as oak bark, cinchona bark, and 
most of the vegetable infusions, while the bowels are regulated 
by alteratives. Along with these give good wholesome food to 
improve the strength of the patient aud the quality of the milk. 
Nutritive, but not stimulating drinks, may be allowed in mode- 
ration. 



526 DISEASES OF MAMMARY GLANDS AND LACTATION.' 

When the flow is greatly in excess, and there is danger of mis- 
chief, as inflammation or abscess, antigalactics may be necessary. 
Of these there are four : iodide of potassium, belladonna, colchi- 
cum and iron. Of the first, Prof. Rousset says it occasions a 
considerable decrease of milk, and prevents or removes milk 
knots, if at the same time the child is not nursed, but the milk 
returns if the medicine is not used longer than two or three 
days! The dose should not exceed 5 to 8 grains daily. The 
secretion of milk can almost be completely prevented, if this 
drug is given on the first or second day after delivery. 

Belladonna appears to act differently according as it is exhibi- 
ted. In 1829 Dr. Fifield, of Weymouth, used it to allay irri- 
tation of the breast. Dr. Schnur in 1834 employed a liniment 
of laurel water f. § ij., sulphuric ether f. ij., extract of bella- 
donna 3ij., to rub the breasts to arrest milk abscess. Dr. 
Goolden employed it, smearing the axilla and breasts freely. 
It entirely relieved the symptoms in several cases. Several 
others have been equally successful. Mr. W. Newman, of 
Fulbeck, England, used it in cases where the suppression was 
desirable because of the death of the child, or the necessity of 
weaning, or where engorgement supervened, and abscess threat- 
ened. He employed the extract softened with glycerine, and in 
every case resolved the engorgement, or arrested the secretion. 
Berry believes that belladonna acts primarily on the muscular 
fibre. The lacteal tubes, in part muscular, are thus dilated, and 
one of two things occurs. The milk is either absorbed, like any 
other effusion, by the absorbents or veins in situ ; or, it may be 
drawn out. This effect is produced by the child, or by a poul- 
tice, which assists the dilatation of the external tubes. In 
threatening abscess, it acts as a sedative. Therefore he believes 
that it merely prevents accumulation. It should not be used 
sparingly, but freely, in the form of extract all over the breast, 
except the nipple and areola. Never fail to wash the nipple 
before applying the child. 

[I can fully substantiate the views of Dr. Rotjth in regard to 
belladonna, having relied wholly upon it for nearly twenty years 



GALACTOEEHCEA. 527 

in a large obstetric practice, and where a good extract was used 
and applied freely, as above, I have never known a failure. The 
secretion may be completely arrested in one breast for any cause, 
while it remains unaffected in the other. Or where abscess is 
feared, the free application from one to three days will positively 
relieve the engorgement, and nursing may continue as desired. 
I generally order 

359. R. Extracti belladonna?, gij. 

Ung. petrolei, % j. M. 

to be rubbed freely over the whole of the breast, except the 
nipple and areola. In several instances I have thus produced 
the toxic effect of the drug, but the secretion was only reduced, 
not entirely arrested, while the symptoms of abscess speedily 
disappeared. — Ed.] 

Goolden says that when milch cows eat the meadow saffron 
(colchicum) in the pasture, their milk is immediately dried up. 

Kottth believes that iron is certainly an antigalactic, especially 
if the astringent preparations are used. Mr. Stanislaus Mae- 
tin, of Auvergne, noticed that drinking ferruginous waters 
caused the milk of animals to dry up. He tried it with a nurs- 
ing woman, and the milk began to disappear. Dr. Richaed- 
son, of Tunbridge Wells, found the quantity of milk thus to 
be decreased in the plethoric, but where there was general 
debility, anaemia, it was increased. 

The following is certainly effective as an antigalactic : 

" Beat up the yolk of an egg to a froth, add olive oil and 
honey, of each two tablespoonfuls, thicken with flour to the con- 
sistence of an ointment, spread it on a rag, and lay it on the 
breast ; change night and morning, and wash the bosom before 
each renewed application." 

Gaednee and Douteepoint speak well of conium. Others 
recommend tobacco and peppermint. 

Where the flow is too free by reason of relaxed fibres of the 
parts, etc., astringent tonics may be given, but we require other 
aid. Cold water may be applied two or three times daily to the 



528 DISEASES OF MAMMARY GLANDS AND LACTATION. 

nipple, not to the breast, and very slightly retractile collodion 
may be brushed around the nipple, and not upon it. The gutta- 
percha collodion is preferable ; it constringes the nipple, and thus 
leaking is prevented ; decoction of oak-bark or alum, with the 
addition of a little gum, is a good local application. Internally, 
nux vomica or strychnine may be given, with or without quinine. 
It strengthens muscular tone and nervous force. 

JOHN Wl. LANE, M. D., LONDON, 

(Medical Press and Circular,) for more than ten years, has em- 
ployed the following method to prevent the secretion of milk in 
the breasts of women who may have had still-born children, or 
who, after having nursed their child for a few months, found it 
necessary to wean it. 

It consists in taking a piece of emplastrum adhesivum of 
about ten inches square, round the corners, cut a hole in the 
centre for the nipple, then from the centre of each corner make 
a straight cut toward and within two inches of the hole; 
having now got it ready, let the patient lie on her back, her body 
being perfectly horizontal ; warm the plaster and place it over 
the breast, then strap one of the lower corners down first, draw 
the opposite one tightly upward and fix its place, then the other 
lower corner, and lastly the opposite upper one, having drawn it 
sufficiently tight first ; now take a piece of plaster two inches 
wide and about sixteen or eighteen inches long, and put it on 
from below and outside the breast, across, close by inside of 
nipple, and fasten the end over the clavicle ; another piece may 
also be put on in an opposite direction, it being drawn over the 
shoulder. Of course, in cutting the plaster and strips, the size 
of the breasts must be taken into consideration, there being so 
much difference in the size of female breasts. 

KESUME OF EEMEDIES. 

Agaricus, gr. iij. in pill, will lessen the secretion in weaning, etc. 
Alumen, in powder, boiled in milk, is an efficient popular means 
to " dry the milk." 



GALACTORRHEA. 529 

Atropia has been found efficient in excessive secretion of milk. 

^Belladonna is probably the most efficient drug known to check 
galactorrhoea. It should be applied locally and taken 
internally. When a woman is subject to galactorrhoea 
during nursing, she should begin the application of 
belladonna ointment to the breasts several months 
before confinement. 

Caffea, has been found effective in the editor's experience. 

*Camphora possesses well -ascertained powers of checking the 
lacteal secretion, and may be advantageously combined 
with belladonna. 

Cannabis Indica-. The volatile oil of cannabis sativa, employed 
in warm embrocations on the breasts, is said by Cou- 
teux to be the best of all agents to check galactorrhoea 
and prevent mammary engorgements. 

Colchicum. It has been observed that cows which eat the 
meadow saffron have their milk dry up ; Dr. Keating, 
of Philadelphia, has observed a similar effect in nurs- 
ing women from the administration of colchicum. 

Conium plasters were formerly used to dry up the milk. By a 
prolonged use of it internally, the mammary gland 
has been known to become atrophied, and its secretion 
to have been gradually suspended. (Stille.) 

Ergota has a positive influence in galactorrhoea. 

Iodinium, in small and repeated doses, will check excessive lac- 
tation. As an ointment to check the secretion of milk, 
Dr. J. L. Ludlow, of Philadelphia, recommends : 

360. R . Iodinii, gr. x. 

Camphorae, 

Extr. belladon., aa gj. 

Cerati resin se co., ^j. M. 

Apply to the breast. 

Linimentum Sapono- Camphor atum, or Opodeldoc Balsam, rubbed 
on the breasts, has been observed to lessen the secre- 
tion, probably owing to the camphor in it. 

Mel. In Italy, inunction of honey to the breast is popular at 
weaning. 

Potassii Chloras has been found by Dr. Alexander Harkins 
efficient in controlling the excessive secretion of milk. 
(Dublin Jour, of Med. Science, November, 1880.) 
34 



530 DISEASES OF MAMMAEY GLANDS AND LACTATION. 

Potassii Iodidum is the most efficient of all antigalactics, and 
the only one which will not disappoint at times. The 
daily dose for this purpose is gr. xx.-xxx. 

Rhamnus Catharticus, in infusion, internally, is recommended by 
Italian physicians. (Fonnsagrives.) 

Salvia. Strong sage tea is a popular remedy to dry the milk at 
weaning time. 



AGALACTIA AND OLIGOGALACTIA. 531 



AGALACTIA AND OLIGOGALACTIA. 



This writer (Therapeutique Appliquee, 1878,) states that the 
agents to increase the secretion of milk find their application in 
three events — 

1. That the milk is insufficient for the child. 

2. That the secretion having become recently suppressed, an 
effort is made to re-establish it. 

3. The sudden cessation of the secretion is coincident with the 
development of symptoms more or less serious in the mother. 

1. Means to increase the milk. True galactogenic agents in- 
crease the quantity without diminishing the quality of the milk. 
Abundant and succulent food, fresh air, plenty of sleep, exer- 
cise, and, if required, bitter tonics, are the more rational mea- 
sures. In Britany, cider, beer, and especially oatmeal porridge, 
have a wide reputation. Of drugs, the Gallega officinalis has 
been asserted on good authority to increase both the quantity 
and the quality of the milk. 

2. Means to re-establish the lactation. When, after temporary 
intervention, it is desired to renew the secretion, the most effi- 
cient agents are — (1) Suction, either by the mouth of the infant 
or the nurse, or by one of the instrumental methods now 
familiar. (2) Topical applications. Of these the leaves of the 
castor oil plant, ricinus communis, deserve special mention. A 
handful of the fresh leaves is boiled in half a gallon of water, 
and the breasts are gently bathed and rubbed with this decoc- 
tion for fifteen or twenty minutes, after which a poultice of the 
boiled leaves is laid upon the breast, and allowed to remain 
there till dry. If the secretion does not reappear in a few 
hours, this is to be repeated. (3) Faradization. The apparatus 
should be at moderate force, the conductors moist ; the muscles 
of the breast should not be included in the current, which 



532 DISEASES OF MAMMARY GLAXDS AXD LACTATION. 

should be confined to the gland, and the sessions should last 
about twenty minutes each. The success with this means has 
been positive. 

3. To prevent accidents from sudden cessation of milk. These 
accidents have been greatly exaggerated by the older teachers of 
medicine, and these effete notions still prevail among the com- 
mon people. When they are believed to be present, the indica- 
tions are to relieve the system by brisk- watery purgatives, or to 
restore the secretion of milk by some of the means which have 
been above mentioned. 

C. H. F. KOUTH, M. D., LOXDOX. 

To induce a flow of milk in the breast, mechanical treatment 
may be applied to the breasts or to the genitalia— as witness the 
effect of the application of the child, and this should be carefully 
persevered in. 

Electricity is a powerful stimulus, as Becquerel, Althaus, 
Skinker, and others have proved in repeated cases, where they 
have succeeded in bringing on or restoring the secretion. Skin- 
ner's mode is : 

Direct. Both poles are covered with moist sponges ; the posi- 
tive is pressed deep into the axilla, and the negative applied to 
the nipple and areola; the current being no stronger than is 
agreeable to the patient. Keep this position for about two min- 
utes. Both poles are then to be inserted into the axilla, and 
gradually brought together, the negative to the sternal, the posi- 
tive to the opposite side of the organ. This may occupy about 
two minutes. 

Intra-mammary. Imbed the poles in the mamma, move them 
about, raising and depressing both at once in and about the organ 
for another two minutes. Perform this daily. Generally one or 
two sittings suffice. 

As there exists great sympathy between the breast and the 
genital organs, the proper functional use of the one will influ- 
ence the other. 



AGALACTIA AND OLIGOGALACTIA. 533 

"Women who are nursing should have abundance of fresh air 
and cleanly surroundings, both of which are aids to lactation. 
As defective lactation is often induced by improper food, this, 
too, should be carefully observed, and supplied in sufficient 
quantities, and of proper quality — fish, rich in phosphorus, as 
oysters and crabs. In his own experience he gives the prefer- 
ence to conger-eel' soup. It is particularly nourishing, and 
readily improves the appetite and strength. Among vegetables, 
are the lentil powder, pea soup and bean soup, all of which im- 
prove the flow and richness of milk. Turnips and potatoes are 
generally regarded as galactagogues. Edible fungi also in- 
crease the secretion. This author particularly lauds the Elopho- 
mices granulatus or Boletus, or deer balls. 

Drinks are useful, but are apt to be abused, as ale or porter. 
Best of all is milk itself, which may be alternated with the malt 
liquors, say two or three tumblers of milk to one of stout, or they 
may be combined. 

Of medicines, he has found useful the Saponaria vaccaria, 
cow basil, vaccaria in strong infusion ; the Sonchus arvensis, 
corn sow-thistle, in decoction ; and the Ricinus communis. The 
latter, Routh was the first to use internally as a decoction, in 
England. Every time the flow has been remarkably increased. 
Some apparent objections to its use are, a sensation of dimness 
of vision ; the dose requires to be increased ; as it appears to lose 
its effect, a temporary suspension is best. Again, it seems to act 
as a diuretic. Here the breasts should be kept warm, and this 
result is less likely to occur. Where the diuretic effect is pro- 
duced, it is well to smear the extract of the leaves over the breast 
in the same way as belladonna is used, with a warm, ordinary 
poultice outside. Dr. Rotjth uses a decoction of the leaves and 
stalks of the Ricinus. When an infusion of this article is given 
to non-suckling women, he has observed an internal pain in the 
breasts which lasts three or four days, and a copious leucorrhceal 
discharge, after which the pain in the breast disappears. 

In two cases he saw emmenagogue eifects. In both, there 
existed uterine congestion. This proves that the remedy should 



534 DISEASES OF MAMMARY GLANDS AND LACTATION. 

not be used in cases where there is disease or irritation of the 
womb. Its action is remarkable in that it is not restricted to 
any particular portion of the suckling period ; it may be imme- 
diate, that is, within twelve hours ; rarely a week elapses before 
its galactagogue effect is observed ; and lastly, its good effects do 
not wear off after a protracted continuance of its use, but its 
omission will often lead to a diminution, if not cessation of the 
secretion. 

The Jatropha manihot, the tapioca or cassava plant, is said to 
act in a similar manner. 

The Coronilla juncia, milk vetch, commonly called the milk 
weed, is second only to the castor oil bean ; the fennel, dill, car- 
rot, and several others, are popularly used, and no doubt more 
experience would prove their value. 

Common salt may be regarded as a specific galactagogue. Cod- 
liver oil undoubtedly would act efficiently, though it has not 
been sufficiently tested.* 

PROP. P. WINCKEL, M. D., ROSTOCK, 

Kequires good nourishment, and tonics or stimulants. In some 
a tea of fennel and anise seed has acted well, or the milk powder 
of pulv. semin. fcenic, sugar, cort. aurant., aa 2 grains, magnes. 
carb., 4 grains. 

Where, on the contrary, the flow was too free, as in galactor- 
rhea, he would restrict the diet, promote copious alvine dis- 
charges, moderately compress the breasts, and nurse less fre- 
quently, and give iodine or iodide of potassium, 5 grains, three 
times a day. 

Kiwisch suggests the injection of a solution of caustic potassa f 
12 to 60 grains of water, into the excretory lacteal ducts. 
Hauck uses compresses wet with decoction or' oak- bark, and 

*For a very interesting article on the subject of galactagognes we refer the 
reader to Kouth's valuable work " On Infant Feeding," to which we are in- 
debted for the foregoing. 



AGALACTIA AND OLIGOGALACTIA. 535 

afterwards a solution of nitrate of silver ; others, quinine, ammo- 
mated iron, alum, quassia, and belladonna. 

Laxge advises the lactate of iron with phosphate of lime. 

Joulix uses Agaricus albus, 1 gramme daily in four doses. 
Veit resorts to purgatives, diuretics, and diaphoretics, and daily 
friction of the skin with hand and brush. Abegg brings on in 
the course of ten or twelve days, by means of the uterine douche, 
a moderate uterine hemorrhage, thus effecting a cure. 

E. CUTTER, M. D., BOSTON, MASS., 

In an article entitled " Food as a Remedy for Agalaxia," says 
that he was led to the consideration of this subject by observing 
dairymen increase the quantity and quality of milk in cows by 
feeding them on bran, shorts, and meal. Hence, he was encour- 
aged to see if nursing women might not do as well if they sub- 
sisted on cereal food that had not been subjected to an abstraction 
of seventy-five per cent, of its mineral ingredients. He em- 
ployed a diet, excluding flour, but including wheat and maize 
unbolted, but ground coarse or fine, and animal food, and or- 
dinary vegetables. In each case there was an abundant supply 
of excellent milk, and the child thrived accordingly. 

There are five grains, namely — wheat, rye, barley, oats, and 
maize — each and all sufficient for the purpose of supplying an 
aliment that contains elements enough to sustain life in health, 
and enough, in the writer's opinion, to make milk. 

It is the excess of starch in flour, and the abstraction of three- 
fourths of its mineral elements, that, in the writer's judgment, 
cause the agalaxia generally observed. 

ROBERT P. HARRIS, M. D., PHILADELPHIA, 

In the American Journal of Obstetrics, vol. II., p. 675, shows 
the value of milk as an article of diet for the nursing woman. 
It should be given in addition to the other diet, and partaken of 
in small quantities frequently repeated. Chocolate, cacao, and 



536 DISEASES OF MAMMARY GLANDS AND LACTATION. 

broma, made with a large proportion of milk, generally pure, is 
of great value, and should always be employed prior to the 
abandonment of the effort to nurse the child. 

DR. ALEXANDER HARKIN. 

' The claims of chlorate of potash as a galactagogue are strongly 
urged by this writer. {Dublin Journal of Medical Science, Nov., 
1880.) He has repeatedly witnessed surprisingly good effects 
from it within a few days. Its influence, however, appears lim- 
ited to the first three months of lactation, and there are some 
constitutions quite uninfluenced by its use. Those which respond 
most promptly are women of a sanguine temperament. The 
milk is also of an excellent quality, and the nursling often im- 
proves marvelously under its use. He usually prescribes it as 
follows : 

361. R . Potassii chloratis, j§ i. 

Aquae, Oj. M. 

Half a wineglassful three times a day. 

There is a condition well known to the profession in which 
ladies complain to their medical adviser of debility and wasting, 
night perspirations, palpitation and pain in the left side under 
the mamma, due to prolonged lactation ; the mother is unwilling, 
or unable perhaps through delicacy of the child, to consent to 
ablactation. In .this case, so very often occurring, by the ad- 
ministration of the chlorate combined with the tr. ferri perchlor., 
she may be enabled to prolong her maternal duties through the 
restoration of her strength, the increase of the secretion and im- 
provement of its character, and the subsidence of the lateral pain. 

BESUME OF KEMEDIES. 



Foeniculum in hot infusion, or a few drops of the oil, are popular 

remedies in deficient secretion. 
Gallega. The goat's rue has a reputation in France. The Gal- 



AGALACTIA AND OLIGOGALACTIA. 537 

lega Virginiana of this country has a similar repute in 
some parts of the United States. (Stille.) 

Gossypium. Dr. Izett W. Anderson, of Jamaica, reports to 
the Obstetrical Society of London that lie has found a 
tea prepared from the green leaves of the Gossypium 
barbadense to be an efficacious galactagogue. 

Jaborandi has been suggested by Roehrig. 

Bicinus. Castor-oil plant leaves are alleged to be very efficient. 
(Pp. 531, 533.) 

Faradization is much praised by French writers. 

Fomentations, warm or hot, will frequently restore the secretion 
when temporarily checked. De Sinety remarks that 
they probably act rather on the imagination than on 
the glands. 



538 DISEASES OF MAMMARY GLANDS AND LACTATION. 

DISEASES OF THE NIPPLES 

PROF. FORDYCE BARKER, M. D. NEW YORK, 

For sore nipples, recommends the following : 

362. R . Plumbi nitrat., gr. x.-u. 

Glycerinse, £jj- M. 

He also directs, as soon as the child is taken from the breast, 
that the nipple be painted freely with the compound tincture of 
benzoin. 

If the ulcerative process has commenced, stop nursing from 
that nipple and paint it with a solution of nitrate of silver, of the 
strength of gr. x. to f. 5j. of distilled water. For inflammation of 
the nipple he recommends a soft bread and milk poultice for a 
few hours, and then keep the breast covered with one or two 
thicknesses of linen wet with a solution of lead and opium. 



M. 



After the inflammation is so far subdued that nursing can be 
borne without much pain, he applies the following after carefully 
washing the nipple : 

364. R . Aquse rosse, 

Glycerinae, aaf.^ij. 

Acidi tannici, 3 ij M. 

Ft. lotio. 

(JO Union Medicate du Canada, January, 1879.) The treatment 
recommended by M. Brochard for fissured nipples is so simple 
that it deserves to be popularized. "When chaps exist on the 
nipples, whatever their extent, the nipple should be washed with 
pure water, and then dried and dusted with suberin, which, as 



363. R . Aquse rosse, 


f.%\ 


Liq. plumbi subacet. dil., 


£■% 


Ext. opii aq., 


3J- 


Ft. lotio. 





DISEASES OF THE NIPPLES. 539 

is known, is impalpable cork powder. The author has used it 
for several years, and prefers it to lycopodium for infants. 

Dr. Haussmakn, of Berlin, recommends compresses soaked in 
a five per cent, lotion of carbolic acid, and changed every two 
or three hours, as the best remedy for sore nipples. If both 
breasts are affected, and, nevertheless, suckling has to be 
carried on, the nipple must be carefully washed each time, 
before the infant is put to them, to prevent poisoning by the 
acid. 

The treatment pursued by Dr. Huebner, of Dresden, Saxony, 
in all lesions of the nipple and areola, consists in the constant 
application, day and night, of lukewarm compresses, wet with 
lead-water ; fissures, ulcers and excoriations being touched once 
or twice a day with balsam of Peru, and the breast well sup- 
ported. The child should nurse less often than usual, and, 
if possible, through a nipple-shield. He recommends the warm 
lead-water in mastitis also, to be followed by strapping of the 
breast and free incision, while suppuration is promoted by poul- 
ticing. 

In chaps of the nipple, Dr. Charkier, of Paris, recommends 
the employment of perfectly pure picric acid in the following 
formulas : a. One and a half parts to 100 parts of distilled 
water ; b. one part to the 100 parts. After thoroughly cleans- 
ing the nipple with tepid water, the solution a. is to be applied 
every morning with a pencil to the cracks; and immediately 
after suckling, the nipple is to be held for four minutes in a 
glass containing the solution b. The infants do not notice the 
bitterness of the medicine, and willingly take the breast. 

Dr. Le De Bordier, of Paris, thinks that in obstinate fissure 
of the nipple, quinine will prove to be of the greatest service ; and 
during a long experience of it, has always found that a cure was 
effected in from three to five days. He generally prescribed a 
dose of 6 grains early in the morning, and a similar dose about 
eleven o'clock a. m. Local treatment was considered of secondary 
importance, being confined chiefly to poultices and some simple 
wash or salve. 



540 DISEASE OF MAMMARY GLANDS AND LACTATION. 

MR. ROBERT DRUITT, LONDON. 

365. R. Acidi tannici, gr. iv. 

Aqua? destillatae, f-3vj. M. 

This solution, as well as ointments and glycerites of tannin, is useful in 
cracked nipples. It should be applied on lint covered with oiled silk. 



DR. BLACQUIERES, FRANCE. 

366. R . Extract! krameriae, gr. xv. 

Olei amygdalae dulcis, f.^ss. 

Butyri cocoa?, g ijss. M. 

To be applied to cracked nipples when the child has ceased to nurse ; to be 
removed before nursing. 

367. R. Zincioxidi, 

Sodii boratis, aa gr. iss. 

Olei amygdalae dulcis, f. g iss. 

Butyri cocose, p i y « 

Olei bergamii, gtt. v. M. 

A useful liniment for cracked and chapped nipples. 



GERMAN HOSPITAL, PHILADELPHIA. 

368. R . Extracti opii, gr. iss. 

Liquoris calcis, f-3 v » 

Olei amygdalae dulcis, £.?Hj- M. 

Dissolve the extract of opium in the lime-water and the oil, and shake 
vigorously. 

MR. ERASMUS WILSON, LONDON. 

The mucilage of acacia is a useful application to sore nipples. 
It should be penciled on the part immediately after suckling, and 
the nipple then be protected by a leaden shield. Or the follow- 
ing powder may be applied : 

369. R . Acaciae gummi pulveris, 

Sodii biboratis, aa 3 ss. M. 

SAMUEL SLOAN, M. D., GLASGOW, 

(Obstet. Jour. Grt. Brit , Jan., 1878,) gives this plan: Carefully 



DISEASES OF THE NIPPLES. 541 

wash off the nipple with tepid water after each nursing; then 
wash it with weak spirit lotion, and glycerine, to prevent drying; 
or, if the excoriation be advanced, add an astringent, as tannin 
or a we;rk solution of nitrate of silver. If the part be not in- 
flamed, to protect the nipple use a shield and apply a mild oint- 
ment, as oxide of zinc. If the nipple be retracted, gently draw 
it out with a breast pump. If still painful, use a glass nipple 
with a rubber teat. This ought to be of a proper shape ; if too 
narrow, it constricts the nipple and occludes the ducts ; if too 
long, a vacuum is caused between the extremity of the nipple 
and the mouth of the child, so that it cannot draw the milk 
into the teat. If too long, it will also tickle the fauces of the 
child. 

Before applying the child to this nipple, the latter ought to be 
filled with some of the mother's milk ; or, if this is not practi- 
cable, with sweetened milk and water. Some children take so 
kindly to this artificial nipple that it is difficult, after being long 
accustomed to it, to persuade them to use their mothers nipple 
again. But, should only one nipple be affected, this will not 
readily happen, especially if the artificial teat be small enough. 
The shield and teat in one piece, made of India rubber or other 
soft material, as softened ivory, will make suction easier for a 
weakly child, if it can be borne by the mother. There is, how- 
ever, with its use, considerable compression of the nipple by the 
child's gums. A good artificial nipple has yet to be devised. 
If the nipple-shield can be borne, and the child can be coaxed 
to use it, there will be little difficulty in curing the nipples on 
general principles. In the event of excoriation of the nipple 
continuing after this attempt with the artificial nipple, and ulcera- 
tion setting in, there remains no course but to take the child at 
once from that breast until the part is sufficiently restored to 
permit of its re-application. And here the careful use of a good 
breast-exhauster is important. For, should the breast become 
engorged while the nipple is tender, there is every prospect of 
abscess of the breast taking place. No matter how tender the 
nipple may be, a careful regulation of the compression ball by 



542 DISEASES OF MAMMARY GLANDS AND LACTATION. 

the hand, with occasional relaxation of the nipple to prevent 
occlusion of the lactiferous tubes, will always result in the almost 
painless removal of the milk; though, should the breast be 
hard and yet no milk come, gentle friction at the periphery of 
the breast may be required to expel the milk from the gland 
proper into the lactiferous reservoirs under the areola, whence 
the breast-exhauster will readily withdraw it. It will now be a 
comparatively easy matter to heal the nipple, since the first step 
in treating a disease is to remove the cause; the impracticability 
of doing this rendering the treatment of the nipple so unsatis- 
factory. If there be ulceration, careful washing and drying of 
the nipple, and the application of the solid nitrate of silver to 
the part affected only, will generally suffice. This treatment by 
a "tough caustic point" is, when combined with the use of the 
nipple-shield, a certain cure of the fissures which occur around 
the base of the nipple. If the part be inflamed, sedative appli- 
cations or poultices will of course be the first indication. Should 
the affection of the nipple arise from an aphthous condition of the 
child's mouth, the application of borax and glycerine, or chlorate 
of potassa dissolved in glycerine, is the proper treatment for the 
nipple as for the mouth. Perhaps it may suffice to point out, 
regarding some recent investigations which have been made as 
to the quality of the milk as a factor in the production of sore 
nipples, that where one nipple only is affected, this condition of 
the milk can have only a very limited effect as an exciting 
cause. 

It is pleasing to pass from the too ofter disappointing treat- 
ment of tender nipples to consider the possibility of having the 
nipples perform their natural functions without the usual morbid 
results. 

It has been customary to order, as a prophylactic, weak spirit 
and water, or other mild astringent, but no evil results from the 
application of stronger astringents. As an astringent, however, 
especially if strong, is likely to cause a hardening only, and not 
a toughening of the nipple, we may have this organ cracking as 
soon as the outer film of hardened cuticle is removed, on the 



DISEASES OF THE NIPPLES. 543 

first application of the child to the breast. To obviate this, mix 
glycerine with the astringent, and some fatty substance, as lard. 
The selection of the particular astringent is, of course, of im- 
portance ; but the thoroughness with which it is applied is more 
so. The solution preferable is made thus : A large teaspoon ful 
of dry tea is put into a two-ounce vial, one ounce of brandy 
and a quarter of an ounce of glycerine are added, and, after a 
few days, with occasional shaking, the solution is ready for use. 
For two or three months previous to parturition, the nipples 
should be thoroughly washed every night with cold water and 
glycerine soap, dried, and the above solution carefully brushed 
over the nipple, but especially around the base and into the 
apex. This is left on all night, and, in the morning, the lard is 
rubbed well in. 

During this treatment the dress ought to be loose ; and, if the 
nipples are at all retracted, they ought to be drawn out occasion- 
ally by suction or with the fingers and thumb. A circular piece 
of some unirritating material, with a hole in the centre, might 
be used in severe cases. 

When the child is born, examine the nipples and breasts. If 
the latter are flaccid, do not put the child early to the nipple; 
and, when the milk has appeared, advise the application of the 
child at intervals of not less than two hours, and to both nipples 
at each application, giving careful instructions against letting the 
nipple remain in the child's mouth after it has emptied the 
breast, and especially against allowing it to sleep at the breast. 
The nipple is to be moistened with water or saliva before apply- 
ing the child to it ; and, when the infant quits the breast, the 
nipple should be washed with a mild astringent and antiseptic 
solution with glycerine; as a teaspoonful each of whiskey, 
tincture of arnica, and glycerine in a wineglassful of cold water. 
The nipple, as soon as the infant leaves the breast, is washed 
with this and partially dried, and a nipple-shield at once applied 
to protect the nipple from friction against the dress. 



544 DISEASES OF MAMMARY GLANDS AND LACTATION. 



Of soothing applications, in mild cases, gam, honey, solution 
of tolu, or Friar's balsam, may be applied with a camel's-hair 
brush after each act of suckling. Often, melted mutton fat, put 
on warm and allowed to cool, will heal such sores when every- 
thing else fails. Fuller's earth or bismuth are useful, but the 
civeolla levigata is a powder superior -to any other. It is 
eminently soft, and will sometimes cure the most obstinate sores. 

Caustics are efficacious if employed skillfully. A solution of 
5 to 10 grains nitrate of silver, in an ounce of water, or 10 
grains of chlorate of potassa, or bicarbonate of soda, will prove 
very healing. 

Shields aid greatly by protecting the part. The caoutchouc 
nipple is preferred. Stretched on a glass or wooden base, they 
are better. Or the nipple may be wholly of glass or wood. It 
should fit the mother's nipple exactly, and not be too deep. 

However, prevention is better. For two months or so before 
delivery, the nipple should be carefully sponged night and 
morning with some astringent lotion, as oak-bark, or cologne 
water, to overcome the delicacy of the skin, and the nipple 
brought out by the use of the shield. 

E. W. SAWYER, M. D., CHICAGO. 

This writer, in the Chicago Med. Jour, and Exam., Dec. 1877, 
advises to remove the organ from the irritation by the use of a 
shield. They are all made to cover the nipple as a thimble, and 
rest air-tight upon the breast, and are surmounted with a false 
nipple of caoutchouc. If aspiration is applied to the rubber 
nipple, an incomplete vacuum is formed in the shield, which is 
filled by the milk from the ducts. The most efficient, at the 
same time the cheapest and most simple variety of nipple-shields, 
is a plain bell-glass, with a broad base to rest upon the breast. 
If the bearing surface of the shield is wetted with saliva or 
glycerine, it will fit upon the breast more tightly. 



DISEASES OF THE NIPPLES. 545 

It is true that the use of this kind of cupping-glass is not 
always free from pain, because it induces an engorgement of the 
nipple ; but there is no other way in which the nipple can be 
placed so nearly at rest, at the same time that lactation is kept 
up. The immediate relief and rapid improvement which have 
followed the temporary use of this means, in cases where all sorts 
of lotions and collodion coating had failed, is surprising. 

It sometimes happens that the child is not vigorous enough to 
draw the milk through the shield ; then the aspiration should be 
made by an adult. In this manner the breast can be sufficiently 
emptied to protect it from trouble, until the lesion of the nipple 
has recovered. In the meantime the child can be sustained 
from the sound breast. Sometimes both nipples are the seat of 
lesions at the same time. Under these circumstances, if the 
child is unable to draw the milk through the shield, some other 
means must be devised, so that the milk may be saved for the 
infant. Make use of that simple form of breast-pump, which is 
practically like the nipple-shield. The bell-glass has a diverticu- 
lum, in which the milk is collected ; and in place of the false 
nipple, there is a large rubber bulb, by means of which the 
vacuum is made. The milk can be poured from the receptacle, 
as often as filled, kept warm, and fed to the child with the spoon, 
or the simple nursing-bottle. 

To cure the ulcers and fissures after the part is thus placed at 
rest, the benzoated zinc ointment is best. Wash the part carefully 
with castile soap and water, and cover the entire nipple and 
areola with the ointment. This need not be removed before 
drawing the milk through the shield. A few drops of carbolic 
acid will increase the efficiency of the ointment. For very red 
and highly-inflamed nipple, the best is a lotion of acetate of lead. 
•This must always be washed off before the milk is drawn. If 
the ulcers are indolent, touch them with nitrate of silver. Ordi- 
narily the ulcer needs only to be kept clean. 

If the fissures are deep, glue the wound by coating it with 
collodion. 

35 



546 DISEASES OF MAMMARY GLANDS AND LACTATION. 
PROF. W. S. PLAYFAIR, M. D., LONDON. 

Prepare the nipple during the latter months of pregnancy, by 
daily bathing it with a spirituous or astringent lotion, as cologne 
and water, or a weak solution of tannin. Wash and dry the 
nipple after each act of nursing, and if tender, protect it with a 
shield. Dr. Wilson, of Glasgow, in fissures of the nipple, uses 
a lotion of ten grains nitrate of lead in - an ounce of glycerine, 
applied after each time of nursing, and the nipple carefully 
washed before the child is allowed to nurse. 

This author finds nothing so good as a lotion of one-half an 
ounce each of sulphuric acid and glycerine of tannin, and an 
ounce of water, the beneficial effects of which are sometimes 
remarkable. 

PROF. WM. LEISHMAN, M. D., GLASGOW, 

Uses in obstinate cases : 

370. B . Ac. tannici, gr. iij. 

Glycerini, f. 3 ss. 

Ung. cetacei, ^j. M. 

In fissures, introduce this by means of lint. If the margin be 
callous, apply solid nitrate of silver. 

PROF. FLEETWOOD CHURCHILL, M. D., DUBLIN, 

Prefers nitrate of silver in weak solution applied after each suck- 
ling. Mr. Druitt recommends five grains pure tannin in an 
ounce of distilled water. Dr. Johnson applies alternately : 

371. R. Sodas boracis, gij. 

Cretae prsep., 5j. 

Spt. vini, 

Aq. rosae, aa f.^iij. M. 

Ft. lotio. 

372. B • Cerae albae, % ivss. 

01. amygdal. dulc, ^*i§j- 

Mel. despumat., f. ^ ss. 

Dissolve by heat, then add by degrees, 

Bals. Peruvian., f.^ijss. M. 

Ft. unguent. 



DISEASES OF THE NIPPLES. 547 

Drs. McClixtock and Hardy use tincture of catechu. 
M. Bourdell applies lint soaked in tincture of benzoin, re- 
peated so as to form a coating over the sore. 

SAMUEL SLOAN, M. D., GLASGOW, 

(Obst. Jour. Gt. Brit, and Ire., Jan., 1878,) employs prophylaxis 
against sore nipples. He puts a large teaspoonful of dry tea 
into one ounce of brandy and a quarter of an ounce of glycerine. 
With occasional shaking, after a few days it is ready. For two 
or three months prior to delivery, the nipples are to be washed 
nightly with cold water and glycerine soap, dried, and the above 
solution brushed over the nipple and its base. In the morning, 
lard is well rubbed in. The dress must be loose, and retracted 
nipples drawn out. After delivery, moisten the nipple at each 
nursing, and after it wash with whiskey, tincture of arnica and 
glycerine, each a teaspoonful in a wineglassful of cold water. 
The nipple shield must be used to prevent irritation by the dress. 
When suckling deprives the nipple of its natural oil, apply fresh 
oxide of zinc ointment. 

PROF. F. WINCKEL, M. D. 

In simple erythema and phlegmon, compresses wet with lead- 
water may be applied, taking care to cleanse the nipples before 
nursing. If there are slight erosions or excoriations, use a solu- 
tion of nitrate of silver, one part to thirty; or alum, sulphate of 
zinc, etc., or tannin, one to fifty. Ulcers may be covered with 
balsam of Peru or copaiva, always using a shield to prevent a 
continuance of the irritation. When the raw spots remain, or 
the ulcers increase, the patient has fever, etc., wean the child. 
Velpeau uses lotions of lead-water, or of oil and red wine, oil 
and lime-water, equal parts, nitrate of silver or sulphate of zinc, 
one or two parts to six of water. Cracks he sprinkles with the 
seeds of earth moss. Inflammation he treats with local discuti- 
ents, mercurial salves and poultices. 



548 DISEASES OF MAMMARY GLANDS AND LACTATION. 

Legroux paints the parts with : 

373. R. Collodion, 30 p. 

Castor oil, J p. 

Oil of turpentine, 1J p. 

And then covers them with gold-beater's skin, perforated with 
pin holes over the apex of the nipple. Soften this covering 
with sugar and water before the child nurses. 

Bouedel and Anselmier use the powder and tincture of 
benzoin. 

Elsasser uses oil of cloves with lime-water in inflammation , 
and in painful bleeding excoriations, applies unguent, rosse, with 
laudanum and oxide of zinc. Ulcers he covers with balsam of 
Peru. 

KESUME OF KEMEDXES. 

Acacia is extolled by Wilson and others as an excellent appli- 
cation. (F. 369.) 

Argenti Nitras is a useful application. The caustic pencil may 
be applied to the fissures or ulcers, or the part may be 
enveloped in lint wet with a weak solution. It is es- 
pecially called for when the fissure is at the base of 
the nipple, and very painful. After the caustic, com- 
pound tincture of benzoin should be applied. 

Balsamum Peruvianum is valuable for local use. Hufeland 
recommends : 



M. 



Dr. Tauszky says (Med. Record, September, 1880,) 
that this prescription has never failed him during a 
practice of twenty years. 
Benzoini Tinctura Comp. may be used with most satisfactory re- 
sults in most cases. Wipe the nipple dry after the 
child has nursed, and with a brush apply four or five 



374. R . Balsami Peruviani, 


f.^ij. 


Olei amygdal. dulc., 


f. % iss. 


Pulv. acacise, 


3ij- 


Aquse rosse, 


*3i- 


Apply five or six times a day. 





DISEASES OF THE NIPPLES. 549 

coats of the tincture. It may at first produce some 
burning, but cicatrization will soon take place under 
this coating. It does not interfere in the least with 
lactation. 

BLmuthi Subnitras. As a neutral protective and absorbent 
powder, none can be found superior to this. 

Oalcis Liquor is a soothing application in light cases. 

Carbolicum Acidum has been much praised by Dr. Haussman, 
of Berlin. (P. 539.) Its advantage is, he claims, its 
capability not only of reaching and superficially cau- 
terizing the open mouths of the finest lymphatic ves- 
sels laid bare in the wound, but also of penetrating 
' completely into them, so as to destroy any parasitic 
germs or infectious organic bodies of any kind which 
may be brought to the nipple by the child's mouth, 
the hands of the mother, doctor, or nurse, or in any 
other way, and so prevent the development of the 
various forms of inflammation in the breast itself. 
The application of carbolic acid is not nearly so pain- 
ful as that of nitrate of silver, and a cure is obtained 
more quickly with the former than the latter drug. 
A strong (five per cent.) solution seems to be decidedly 
more efficacious than a weaker (two per cent.) solution. 

Collodion is a protective agent often of service. Dr. Albert 
H. Smith, of Philadelphia, employs : 

375. R. Emplastri plumbi, gij. 

^Etheris sulphurici, f. ^ss. 

Collodion flexile, f-3J- M. 

Powder the lead-plaster, add the ether, and mix them well 
together before adding the collodion. It makes a creamy mix- 
ture, and is to be applied with a brush over every portion of the 
carefully dried nipple, with the exception of the opening of the 
milk ducts. 

Galla has been found useful by Dr. Q. C. Smith. 

376. R. Puly.gallse, 3j. 

Olei menthse piper., gtt. x. 

Tinct. opii camphor., q. s. M. 

Make a thick paste and apply just after the child nurses. It 
should be removed by gentle washing before the infant nurses 
again. 



550 DISEASES OF MAMMARY GLAXDS AXD LACTATIOX. 

Glycerina is much employed as an excipient. The glyceroles of 
lead, tannin, etc., are frequently efficient. 

Hydrargyri Chloridum Mite. When the ulceration has de- 
stroyed the surface of the nipple, Dr. Barker recom- 
mends that the child be prevented from nursing, and 
the following applied : 

377. R . Hydrargyri chloridi initis, gr. xxx. 

Magnesise, gr. xx. 

Unguenti rosse, |;j. M. 

Rub together very carefully, and prepare fresh daily 

Hydrastis has been found to be a valuable application in cracks 

or fissures of the nipple. 
Iodoformum. Dr. M. O'Hara, of Philadelphia, uses : 

378. R. Iodoformi, gss. 

Collodion, f.^j. M. 

Krameria is popular with some. (F. 366.) 

Picricum Acidum has been extolled by Dr. Charrier. (P. 539.) 

Pix Liquida is a valuable local application in eczematous con- 
ditions of the nipple. 

Plumbi Nitras is, according to Dr. Barker, the most complete 
prophylactic against the occurrence of sore nipple that 
we have. He 'directs, as soon as there is any inflam- 
mation of the nipple, to apply a poultice until the im- 
mediate symptoms are subdued, and then apply a 
solution of nitrate of lead gr. x., to glycerine f. §j. It 
should be used immediately after nursing, having 
w r ashed the nipple perfectly clean. The nitrate is said 
to be of little use after fissures have actually occurred. 

Plumbi Sabacetatis Liquor is a grateful cooling lotion, properly 
diluted. 

Stdicylieum Acidum has been tried with excellent results in 
cracked and lacerated nipples. It is important not to 
apply it too strong, or it will irritate. Numerous and 
careful trials in the Vienna Hospitals have decided that 
the strength must not be over four per cent., as : 

379. R • Acidi salicylici, gr. xv.-xx. 

Alcoholis, q. s. to dissolve. 

Unguenti petrolei, ^j. M. 

Apply on lint, or rub in several times a day. 



DISEASES OF THE NIPPLES. 551 

Sodii Biboras in solution and ointment has a long-standing rep- 
utation. 

Suberin has been recommended. (P. 538.) 

Tannicwm Acidum is an excellent astringent. Dr. S. S. Purple, 
of New York {Medical Record, 1879,) employs: 

380. R. Acidi tannici, 5fj. 

Acaciae niucilaginis, f. J5 iij- 

Aqnse, f.^ij. M. 

It can be applied to the nipple and breast with the finger, and 
should remain exposed to the air until perfectly dry. The glass 
can then be worn over the nipple to protect it from the clothing, 
and he usually had no trouble in the managemeut of the case. 

Dr. Howell recommends the following in the Canada 
Medical Record, 1881 : 

381. R. Tannin, 3J. 

Subnit. bismuth, cjij. 

Vaseline, ^j. M. 

Sig. — To be applied constantly when the child is not nursing. 

Zinci Oxidum is a soothing application in the form of the ben- 
zoated ointment. 



INDICES. 



I. INDEX OF AUTHORS. 



Acosta, Prof., Paris, 151. 

Adams, D. S., U. S., 515. 

Aitken, Win., Edinburgh, 98. 

Alexander, L., Pennsylvania, 78. 

Allen, J. E., 372. 

Allen, Joshua G., Philadelphia, 510. 

Althaus, Julius, 63. 

Arnann. J., Munich, 419, 459, 461, 

463, 467, 483, 488. 
Amussat, 195. 
Anderson, J. W., 537. 
Andrews, E. H., Pennsylvania, 90. 
Anselmeir, 548. 

Anstie, F. E., London, 58, 77, 523. 
Aran, F. A.. Paris, 68. 
Arnold, A. B., Baltimore, 99. 
Ashhurst, John, Jr., Philadelphia, 146. 
Ashwell, S., London, 60, 79, 230, 241. 
Asp, G., Helsingford, 144. 
Atlee, Washington L., Philadelphia, 

30, 
Atthill, Lombe, Dublin, 44, 91, 107, 

122, 144, 155, 176, 191, 209, 228, 

334, 412. 
Aust-Lawrence A. E., England, 212, 

425. 
Aveling, J. H., London, 417. 

Bacarisse, 329. 

Bailly, Dr., Paris, 404. 

Baird, A., Edinburgh, 462. 

Barbiglia, E , 325. 

Barker, Fordyce, New York, 111, 421, 

434, 450, 466, 485, 491, 523, 538. 
Barnes, Robert, London, 34, 44, 53, 

77, 81, 110, 130. 



Bartholow, Roberts, Philadelphia, 42, 

83, 332, 361, 481. 
Bartlett, Dr., New York, 113. 
Bartlett, J. K., 357. 
Battey, Robert, Rome, Ga., 45, 133. 
Bayes, Dr., 215. 
Beach, R. E., Illinois, 161. 
Beck, Snow, 414. 
Bee querel, M., 532. 
Bedford, G. S., New York, 256. 
Beigel, H., 265. 

Bell, Robert, Glasgow, 158, 202. 
Bennett, J. H., Ohio, 379. 
Bennett, J. M., Liverpool, 160. 
Benoist, Dr., 459. 
Bernutz, 480. 

Berry, Wm., Edinburgh, 424. ' . 
Billroth, Prof, Vienna, 31, 288, 497. 
Bischoff, 371. 

Bixby, Geo. H., Boston, Mass., 239. 
Black, J. R , Newark, Ohio, 89, 272. 
Blacquieres, Dr., France, 540. 
Blandford, 433. 
Boinet, A. A., Pans, 46. 230. 
Bond, Henry, Philadelphia, 315. 
Bonnafond, 149. 
Bouchut, E., Paris, 253 
Bourdell, M., 547. 
Boys, Wm., 332. 
Brabazon, Dr., 287. 
Braithwaite, Jas., 387. 
Brandt, Stockholm, 20. 
Braun-Fernwald, Vienna, 275. 
Braun, Carl, Vienna, 317, 351. 
Bretonneau, Dr., France, 1 06, 329 
Brisbane, Jas., London, 405. 



553 



554 



INDEX OF AUTHORS. 



Brochard, M., 538. 
Brodie, Sir Benj., 103. 
Brown, I. Baker, London, 221, 254. 
Brown-Sequard, Paris, 103. 
Brunninghausen, 318. 
Buckler, T. H., U. S., 153. 
Bumstead, F. J., New York, 256. 
Burns, Bobert, Philadelphia, 95, 312. 
Busey, S. C, Washington, 334. 
Butt, B. L., Alabama, 275. 
Buys, Dr., Bordeaux, 230. 
Byford, W. H., U. S., 85, 120, 200, 
254.' 

Campbell, C. J., Paris, 359. 
Campbell, Henry F., 331. 
Carroll, Dr., U. $., 163. 
Cazeaux, M., Paris, 347. 
Chadwick, J. B., U. S., 139, 472. 
Chambers, Thos. King, London, 100. 
Champonnierre, M. Lucas, Paris, 359. 
Chanier, A., 219. 
Chantreuil, M., 377. 
Charles, Dr., Belgium, 422. 
Chapman, John, London, 97. 
Charcot, Prof., 221. 
Charriere, Dr , Paris, 539. 
Christison, Alex., 413. 
Christie, David, England, 417. 
Chrobak, C, Vienna, 17. 
Churchill, F., Dublin, 41, 90, 137, 314, 

354, 502. 
Clark, C. C. P., 427. 
Clarke, Charles, London, 62, 230. 
Clarke, Daniel, Canada, 416. 
Clay, Charles, London, 320. 
Clav, John, Eng., 210. 
Cleaver, H. T., Iowa, 282. 
Clendenning, 321. 
Coe, A. S., New York, 351. 
Cohen, 320. 

Cohnstein, Heidelberg, 219. 
Cole, B., U. S., 165. 
Coleman, K. T., 428. 
Cooper, Astley, London, 241. 
Copeman, E., Norwich, Eng., 175, 330. 
Copland, Dr., 62, 109. 
Conteux, 528. 

Courty, A , Paris, 48, 57, 168, 232. 
Craig, Prof., Washington, 108. 
Craig, W., Edinburgh, 345. 
Crawcour, J. I., New Orleans, 455. 
Crede, Prof., 401. 
Croom, J. H., Edinburgh, 288. 
Crichton, Dr., 484. 
Curran, J. Waring, Dublin, 41, 104. 



Cutter, Ephraim, Boston, Mass., 46, 
194, 535. 

Dabney, W. C, U. S , 153. 

Da Costa, J. M., Philadelphia, 44. 

Darby, J. T., New York, 244. 

Da Venezia, Dr., Italy, 335. 

Davis, N, S , Chicago, Illinois, 71. 

Davis, Dr., 413. 

Delauny, Dr., 428. 

Demarquay. J. N., Paris, 231. 

D'Espine, 488. 

Despres, A., Paris, 70, 90, 234. 

Dewees, W. P., Philadelphia, 59, 77, 

93, 239. 
Dezon, 309. 
Dickinson, W. H., 91. 
Diday, M., France, 308. 
Dillenberger, Emil, Vienna, 54, 69, 

87. 
Diboue, Dr., 335. 
Donovan, Wm., Edinburgh, 414. 
Doutrepoint, 527. 
Dubelski, Dr., Warsaw, 333. 
Dubois, Paul, 323. 
Dudley, E. C, U. S., 242. 
Duncan, J. Matthews, London, 28, 39, 

67, 152, 250, 446, 494. 
Duncan, M., 423. 
Dunevoz, E., Belgium, 257. 
Dupierris, Dr., Cuba, 460. 
Dunster, E. S., Mich., 212, 350. 
Druitt, Bobert, London, 540. 
Drysdale, Thomas M., Philadelphia, 

30, 67. 

Eckland, Dr., Sweden. 138. 

Edis, A. W., 217, 255.' 

Edis, Thos., London, 182, 215, 229. 

Edwards, Dr., Denbigh, 175. 

Elliott, J. W., 364. 

Ellis, Bobert, London, 146. 

Emmet, Thos. Addis, New York, 178, 

192, 211, 284. 
Engelmann, G. J., 401. 
Etheridge, J. H., Chicago, 111., 115. 
Eulenberg, Albert, Berlin, 329, 330. 
Everett, J. T., U. S., 202. 

Fahnestock, W. B., 362. 

Faille, J. de la, Holland, 198. 

Fehling, H., Leipsic, 427.* 

Field, Henry M., Boston, Mass., 107 

235. 
Fifield, Dr., Weymouth, 526. 
Filho, Dr., 149. 



INDEX OE AUTHORS. 



555 



Finch, T., Illinois, 229. 

Flint, Austin, St., New York, 98. 

Fonnsagrives, J. B., Paris, 53, 68, 

111, 351, 531. 
Forrest, Dr., 415. 
Forwood, W. S. Md., 331. 
Fothergill, J. Milner, London, 42. 
Fournier, M., Paris, 241. 
Fowler, C, N., U. S, 292. 
Frachaud, Dr., 357. 
Frankel, Dr., Breslau, 384. 
Fried rich, Dr., 334. 
Frisbie, C. W., East Springfield, N. 

Y., 70. 
Fritsch, Halle, 364. 
Fritz, Dr., Paris, 55. 
Fuller, C, 333. 

Gaillard, Dr., Paris, 106. 

Galabin, N. L., London, 168, 204, 223. 

Gallard, M. T., Paris, 137, 144, 252. 

Gallois, F. A., Paris, 203. 

Gardner, Dr., 527. 

Garratt, A. C, Boston, Mass., 257. 

Gaudriot, Dr., Paris, 246. 

Gazzo, Jno. B. C, La., 505. 

Gehrung, Eugene C, Mo., 189, 278. 

German Pharmacopoeia, 81. 

Hospital, Philadelphia, 540. 
Gilbert, S. F., Pa., 279. 
Gill, D., Mo., 271. 
Glover, J as. G., London, 448. 
Goldsmith, W. T., Georgia, 171. 
Godson, Clement, London, 177, 315. 
Gooch, 191. 
Good ell, Wm, Philadelphia, 92, 172, 

204, 255, 285, 471. 
Goolden, Dr., 526. 
Gould, S. W., 570. 
Graham, Douglas, Boston, Mass., 63. 
Graves, R. J., Dublin, 50. 
Greene, Dr., 336. 
Greene, W., U. S., 238. 
Greenhalgh, Dr., 158. 
Griffith, G. De Gorrequer, London, 

195. 
Gros, M., 335. 

Gross, Samuel D., Philadelphia, 518. 
Grunewall, 488. 
Guadriot, Dr., Paris, 173. 
Guichard, Dr., Paris, 137. 
Guipon, Dr., Paris, 232. 
Gusserow, A., Germany, 199. 

Hall, Marshall, London, 215. 
Halton, Dr., Dublin, 161. 
Hamburger, Dr., 228. 



Haraelin, E., 321. 

Hamilton, Dr., Edinburgh, 316. 

Hardy, Dr., 259, 547. 

Harkin, A., England, 94, 529. 

Harris, Robert P., Philadelphia, 308, 
347, 535. 

Harrison, Geo. T., New York, 409. 

Hartshorne, Henry, Philadelphia, 62, 
71. 

Hauenstein, J., 376. 

Haussman, Dr., Berlin, 539. 

Hayes, P. S., Chicago, 111., 63. 

Hauck, 534. 

Hecker, Dr., 414. 

Hegar, Dr., 20. 

Henrot, Dr., 170. 

Hertz, 459. 

Herrick, O. E., Mich., 172. 

Hewitt, Grailv, London, 39, 60, 84, 
93, 107, 208," 214, 240, 279. 

Hickinbotham, Dr., England, 129. 
Hicks, Braxton, 170, 259. 
Higginson, 42. 

Hildebrandt, 200, 203, 251, 265, 494. 
Hodge, Pro£, 176. 
Hofmeier, Dr., 373. 
Hogg, Dr., 462. 

Holt, Joseph, New Orleans, 454. 
Hoist, 255. 
Home, 62. 
Honing, Dr., 313. 
Home, J. F., 324. 
Horton, H. L., 381. 
Hopkins, 319. 
Hospitals of Paris, 185. 
Hospital of University of Pennsylva- 
nia, 132. 
German, 540. 
Philadelphia, 132. 
Vienna, 550. 
Woman's, 137. 
Howe, J. W., New York, 418. 
Howell, Dr., 551. 
Huguier, Dr., France, 27. 
Huebner, Dr., Dresden, 510, 539. 
Hufeland, Dr., 268. 
Huter, Dr., 318. 
Hyatt, H. O , 404. 
Hunt, Harry, England, 321. 
Hunter, E. H. W., 45. 

Image, F. E., 332. 
Izard, Walter, Va., 453. 

Jackson, A. Beeves, Chicago, 111. 
145, 258. 



556 



INDEX OF AUTHORS. 



Jacobi, Mary Putnam, New York, 76. 

Jacquet, 428. 

Jaret, Dr., 59. 

Jenks, E. W., Chicago, 111., 79, 322, 

495. 
Jewett, Theodore, Bowdoin College, 

70. 
Johnson, Dr., 546. 
Johnson, W. B., Alabama, 113. 
Jones, G. S., Boston, Mass., 258. 
Jones, M. O., Chicago, 111., 331, 335. 
Jones, J., U. S., 201. 
Joulin, 535. 

Kaltenbach, Dr., Germany, 20. 

Kammerer, Joseph, 139. 

Keating, W. V., Philadelphia, 204. 

Keiier, C. B., Indiana, 506. 

Kelly, Bernard, London, 397. 

Kerr, E. W., England, 415. 

Kijanizyn, J., Russia, 292. 

King, E. W., U. S., 376. 

Kimball, G., Lowell, Mass., 47. 

Kinsman, D. IS"., 143. 

Kirkpatrick, J. P., Dublin, 184. 

Kisch, E. H., 142. 

Kiwisch, 206. 

Klebs, Prof., Prague, 462. 

Kluge, Dr.. 318. 

Koeberle, Prof., 28, 158, 168. 

Koehler, Dr., Germany, 405, 416. 

Koening, Dr., 511. 

Kubker, Vienna, 466. 

Kucker, Dr., Germany, 340. 

Kunst, A. H., 430. 

Kurz, Edgar, Tubingen, 507. 

Laferld, Dr., Malta, 312. 

Lane, John Wm., London, 528. 

Lange, 535. 

Langlebert, Edmund, Paris, 231. 

Larrabee, J. A., Louisville, Ky., 459. 

Laycock, Dr., 104. 

Leblond, A., Paris, 137, 142, 147, 226. 

Legg, J. W., 346. 

Legroux, 547. 

Leishman, Wm., Glasgow, 310, 316, 

329, 348, 469, 480. 
Lente, F. V., N. Y., 335. 
Lever, 321. 
Liebman, 138. 
Lisfranc, Dr., Paris, 71. 
Lister, Dr., London, 500. 
Locock, Charles, 62, 78. 
Long, W. H., 379, 416. 
Loudon, Charles, 215. 



Ludlow, J. L., Philadelphia, 529. 
Lusk, W. T., New York, 360, 386. 
Lyman, G. H., 97. 

Macan, A. V., London, 382. 
Macdonald, Angus, Edinburgh, 302, 

424. 
Madden, T. M., London, 204. 
Magendie, Dr., 450. 
Maissonneuve, M., Paris, 23i, 522. 
Mann, Dr., 416. 
Marsh, H., 108. 
Martin, S., 527. 
Martin, Dr., Berlin, 367. 
Massmann, Dr., 427. 
Mauriceau, Prof., 307. 
Maury, Dr., New York, 384. 
Mayrhofer, Prof., Vienna, 216. 
McClintock, Dr., London, 194," 203, 

547. 
McDougal, J. A., 321. 
McGuire, Hunter, Virginia, 503. 
McMechan, J. C, 487. 
Meadows, Alfred, London, 94, 221, 311. 

433. 
Meissner, 319. 
Meyr, J., Germany, 21. 
Miller, Hugh, Glasgow, 449, 507. 
Milne-Edwards, Dr., 384. 
Milton, Dr., 273. 

Mitchell, S. Weir, Philadelphia, 101. 
Moller, Dr., Vienna, 417. 
Morgan, Mr., Litchfield, Eng., 124. 
Morris, John, Maryland, 245. 
Morton, D., United States, 384. 
Moses, S. S., United States, 399. 
Muller, P., Berne, 323. 
Mulreany, Jos., England, 248. 
Munde, Paul, New York, 13d. 
Murphv, P. J., Washington, 461 
Mussy, G. de, 143. 

Napier, A. D. L , London, 401. 
Napheys, Geo. H., Philadelphia, 300. 
Neal, Richard, London, 259. 
Neftel, Wm. B., New York, 80, 233. 
Neuman, Prof., 341. 
Newman, T. J., Chicago, 41. 
Newman, W., Fulbeck, England, 526. 
Newman, Robert, United States, 291. 
New York State Women's Hospital, 

137. 
Niemeyer, Felix von, Tubingen, 100. 
Nceggerath, E , New York, 353. 
Nunn, J. R (J United States, 377. 



LN'DEX OF AUTHORS. 



557 



CHara, Michael, Philadelphia, 550. 
Olshausen, R., Germany, 31, 38. 
Oppenheimer, L. S., Louisville, Ky., 

97, 292. 
Ore, D., Bordeaux, 361. 
Osterlop, Dr., Dresden, 459. 

Pajot, Prof., Paris, 141. 

Pallen, Montrose A., New York. 184, 

247, 25S, 349. 
Pan as, M., Paris, 47, 86. 
Paquelin, Dr., 211. 
Park, R., United States, 144, 439. 
Parish, W. H., Philadelphia, 457. 
Parry, John S., Philadelphia, 348, 502. 
Parvin, T., United States, 306. 
Peaslee, E. E., New York, 45, 203. 
Penrose, E. A. F., Philadelphia, 411. 
Pereira, 62, 237. 
Peters, Dr., Prague, 256. 
Philadelphia Hospital, 132. 
Phillips, C. D. F., London, 62, 77, 78, 

221, 236, 256, 385. 
Piffard, H. G., New York, 256. 
Pinard, A., Paris, 336, 344. 
Pitois, Prof., Eennes, 333. 
Playfair, W S., London, 124, 308, 340, 

356, 381, 410, 420, 432, 457, 471. 
Porter, F. T., Dublin, 59. 
Power, H., 341. 
Powers, J. L., Iowa, 509. 
Purple, S. S., New York, 551. 
Putnam, S., Vermont, 431. 

Quissac, J., France, 97, 114, 234. 

Ramsbotham, Dr., 446. 

Banking, G. S. A., United States, 90. 

Ranking, J. E., 389. 

Recamier, Madame, 97. 

Reamy, Thad. A., Ohio, 385. 

Reid, A. P., Montreal, 106. 

Reid, Wm. L., 369. 

Reynolds, 321. 

Richardson, A., 370. 

Richardson, W. L., United States, 385. 

Richter, Carl, Berlin, 456 

Ricord, 329. 

Rigby, 433. 

Ringer, Dr., London, 58, 90, 93. 

Riviere, Dr., 329. 

Roberts, F. T., Manchester, 105, 159. 

Robinson, C. E., Iowa, 282. 

Eokitansky, Jr., 319. 

Ronzier-Joly, 58. 

Rousset, Prof., 526, 



Routh, C. H. F., London, 204, 525, 532, 

544. 
Russel, P. E., England, 353. 

Sale, E. P., Aberdeen, Miss., 142. 
Sawyer, E. W., Chicago, 111., 544. 
Saxe, A. W., California, 283. 
Scanzoni, Prof., Germany, 170, 226, 

229, 320. 
Scheel, 319. 

Schmidt and Urner, 167. 
Scholler, 318. 
Schroeder, Karl, 136, 170, 254, 257, 

313, 318, 420. 
Schucking, 281. 
Schultze, B. S., Jena, 165. 
Schnerr, Dr., 526. 
Schott, A., 95. 
Scudder, 286. 

Sell, E. H. M., New York, 385. 
Seyfert, Dr., 463. 
Simon, 19. 
Simpson, A, R., Edinburgh, 24, 96, 

m 205, 295,458. 
Simpson, Sir Jas. Y., Edinburgh, 173, 

521. 
Sims, J. Marion, New York, 85, 175, 

326. 
Sinety, L. de, Paris, 38, 47, 57, 75, 125, 

153, 197, 206, 233, 264, 268, 281, 521. 
Si red ay, 53. 
Skene, A. J. C, New York, 163, 242, 

276, 281, 285, 310, 435. 
Skinner, 532. 

Sloan, S., Glasgow, 540, 547. 
Smith, Albert H., Philadelphia, 188, 

378. 
Smith, Q. C, California, 503, 549. 
Smith, Tyler, London, 92, 237, 339. 
Spiegel berg, Otto, Breslau, 425. 
Stadtfeldt, Prof., 367. 
Standes, Dr., 373. 
Staples, G. M., 426. 
Stephenson, W., London, 384. 
Stilie, Alfred, Philadelphia, 58, 324. 
Stokes, J. G., Illinois, 322. 
Storer, H. R., Rhode Island, 258. 
Strudwick, Dr., 409. 
Stumpf, Dr., German v, 94. 
Sussdorf, G. E., New York, 110. 
Swayne, J. G., England, 314. 

Taliaferro, V. H., Atlanta, Ga , 135, 

171. 
Tait, Lawson, Birmingham, Eng , 43, 

66, 132, 232, 247. 269. 



558 



INDEX OF AUTHORS. 



Tanner, T. H., London, 59, 240, 336, 

523. 
Tarnier, S., Paris, 63, 318, 321, 328, 

340. 
Taylor, J. E , United States, 375, 400. 
Tausky, E , United States, 86, 267. 
Tedenap, M., 332. 
Thierry, Prof., Brussels, 105. 
Thompson, Ashburton, London, 504. 
Thompson, H., London, 280. 
Thomas, J. P , United States, 157. 
Thomas, T Galliard, New York, 34, 

46, 52, 64, 82, 107, 130, 150, 162, 164, 

190, 418, 469. 
Tilt, Edward J., London, Eng., 44, 52, 

58, 60, 83, 90, 96, 101, 106, 164, 173, 

207, 215, 231, 269, 334. 
Trask, Dr., London, 415. 
Travers, Dr., 469. 
Trelat, Prof., Paris, 230. 
Trenholm, E. H., Montreal, Canada, 

461. 
Trousseau, Prof., Paris, 79. 
Tuke, Dr., London, 432. 
Turn bull, Lawrence, Philadelphia, 

221. 
Tye, Geo. A., Canada, 412. 

Urner, Dr., Germany, 167. 

Van De Warker, Ely, New York, 213, 

327. 
Varaseau, 384. 
Veit, Dr., 170, 535. 
Velpeau, Prof, Paris, 195. 
Yenezia, Dr., 335. 
Verneuil, Prof, Paris, 199. 
Vidal, Prof., 248. 
Vienna Hospitals, 550. 
Vigo, De, 518. 



Walker, J. W , Indiana, 200. 
Wallace, Ellerslie, Philadelphia, 187. 
Walters, John, London, 413, 
Ward, O., Tennessee, 76. 
Warker, E. Van de, United States, 213, 

337. 
Warren, John S., New York, 286, 327. 
Watkins, A. F., 361. 
Weber, F., St. Petersburg, 252. 
Weber, B. von, 367. 
Wells, Spencer, London, 30, 205. 
West, Dr., -London, 273, 482. 
Westmoreland, J. G., United States, 

210. 
Whitaker, J. T., United States, 458. 
White, H. B.. Brooklyn, N. Y., 425. 
White, James P., Buffalo, N. Y., 138, 

165, 461. 
Wiglesworth, Arthur, England, 383. 
Wilkins, W. W., New Hampshire, 139. 
Williams, John, London, 48, 74, 183, 

205. 
Williams, P., 161. 
Williams, Wynne, London, 208. 
Wilson, Ell wood, Philadelphia, 80. 
Wilson, Erasmus, London, 273, 540. 
Wilson, H. P. C, Maryland, 411. 
Wilson, Dr., Glasgow, 546. 
Wiltshire, A., England, 259. 
Winckel, F , Germany, 258, 277, 289, 

403, 479, 534. 
Windelband, Dr., 416. 
Woodbury, Henry E., Washington, 73, 

140. 
Woodruff, Julian S., South Carolina, 

73. 
Workman, J., Toronto, Canada, 93, 

415. 
Wright, C. O., Cincinnati, O., 272. 

Zweifel, Prof., Erlangen, 371. 



INDEX OF KEMEDIES AND KEMEDIAL MEASUEES. 559 



II. INDEX OF REMEDIES AND REMEDIAL 
MEASURES. 



Abdominal frictions, 319, 387. 
section, 482. 
^A^bortifacients, 322. 
Abscess of mamma, to prevent, 498. 
Abstention from fluids to cure mam- 

mitis, 504. 
Acacia, 109, 330, 540. 
Acetum, 167, 413, 458. 
Achillea millefolium, 58. 
Acid, with opium, 313. 

nitrate of mercury. See Liquor. 
Acida, 279, 313. 
Acidum aceticum, 167, 285, 314. 

arseniosum, 77, 89, 256, 312. 
benzoicum, 276, 352. 
bichloraceticum, 167. 
boracicum, 144, 238, 260. 
carbolicum, 113, 143, 167, 
229, 272, 292, 330, 447, 
455, 549. 
carbonicum, 226. 
chrysophanicum, 341. 
chromicum, 143, 158. 
citricum, 330, 352. 
gallicum, 92, '347. 
hydrobromidum, 449. 
hydrocyanicum dilutum, 257, 

273. 
muriaticum dilutum, 506. 
nitricum, 143. 
nitro-muriaticum, 286. 
phosphoricum, 154. 
picricum, 539. 
pyroligneum, 168. 
salicylicum, 170, 234, 279, 

550. # m 
sclerotinicum, 94, 205. 
sulphuricum aromaticum, 
205. 
dilutum, 95. 
sulphurosum, 260. 
tannicum, 95, 277, 278, 281. 



Acidum tartaricum, 352. 
thymicum, 251. 
Aconitia, 271. 

Aconitum, 58, 332, 458, 504. 
Acosta's gas cautery, 149. 
Actea alba, 398. 

racemosa, 523. 
Actual cautery, 114, 149. 
Acupressure, 518. 
Mther. See Ether. 
Agaricus albus, 524. 
Air pessary, 315. 
Alcohol, 285, 329, 340. 

as an anaesthetic, 361, 384. 
Alimentation, rectal, 331. 
Alkalies in cystitis, 280. 
vaginitis, 236. 
sterility, 219. 
Alkaline baths, 72, 128. 

carbonates, 219, 290. 
purgative water, 352. 
Allium, 102. 
Aloes, 58, 237, 322. 

cum myrrha, 109. 
Aloin, 58, 345. 
Althaea, 170. 

tents, 170. 
Alumen, 89, 96, 237, 528. 
Aluminae nitras, 271. 
Ammoniae acetatis liquor, 76. 

aquae, 59, 271. 
Ammonii benzoas, 276. 
bromidum, 89. 
carbonas, 452. 
chloridum, 44, 58, 76, 238. 
iodidum, 506. 
valerianas, 68. 
Ammonium, 102. 
Amyl nitrite, 76, 384, 415. 
Amylum, 266. 
Anaesthetics, 19. 

in labor, 355, 382. 



560 INDEX OF EEMEDIES AND EEMEDIAL MEASTJEES. 



Anisum, 534. 
Anthemis, 102. 
Antigalactics, 527. 
Antirnonii chlorid.um, 168. 

et potassii tartras, 44, 384. 
Antipyretics, 450. 
Antiphlogistics, 499. 
Antiseptic marine lint, 242. 
midwifery, 364. 
surgery of the mammse, 
500. 
Antiseptics, 248, 364. 
Apiol, 59, 76. 
Aqua ammonise, 59, 271. 
calcis, 238, 271. 
pimentse, 230. 
Arbor vitae, 256. 
Argenti nitras, 59, 122, 238, 278, 287. 

oxidnm, 89. 
Armoracia, 332. 
Arnica, 458. 
Arsenici iodidum, 256. 
Arsenicum, 312, 518. 
Artemisia vulgaris, 59. 
Aspiration, 481. 
Asafcetida, 65, 103, 312. 
Astringent injections, 241. 
lotions, 544. 
for nipples, 544. 
Atropia and atropine sulphas, 44, 285, 

330, 332, 381. 
Aurantii flores, 103. 
Auri et sodii chloridum, 102. 
Aurum, 39. 

Balneo-therapy, 21. 
Balsamum Peruvianum, 272, 548. 
Bandaging in mammary sinuses, 504. 
in phlegmasia dolens, 486. 
Barnes' method for premature labor, 

317. 
Barnes' rubber bag, 378. 
Baths, 21, 63. 
hot, 404. 
shower, 76. 
sool, 21. 
Turkish, 349. 
Battley's solution, 340. 
Belladonna, 59, 77, 268, 290, 329, 384, 

442, 456, 500, 529. 
Bennett's caustic, 170. 
Benzoinum, 545. 
Berberise sulphas, 89. 
Bismuthi oxidum, 273. 
phosphas, 332. 
subacetas, 328. 



Bismuthi subnitras, 108, 238, 281, 330, 

549. 
Black cohosh, 337. 
Blisters, 45, 463, 482. 
Boletus, 533. 

Boracicum acidum. See Acidum. 
Bougies, 281, 289. 
Brandy. See Stimulants. 
Braun's colpeurynter, 378. 
Brick clay, 258. 
Brominium, 44, 77. 
Buchu, 276, 
Butyrum cocose, 112. 

Carlsbad salts, 259. 

Caffea, 90. 

Cajuputi oleum, 103. 

Calcii chloridum, 201, 203. 
phosphas, 154. 

Calisaya, 113. 

Calumba, 331. 

Camphora, 44, 77. 

Camphorse monobromidum, 220. 

Canella, 232. 

Cannabis Indica, 65, 89, 290, 314, 321, 
413. 
sativa, 330. 

Canquoin's paste, 149. 

Cantharides, 59, 323. 

Capsicum, 414. 

Capsules, 142. 

Carbolic acid. See Acidum. 

Carbolized oil and lotions, 369. 

Carbonate of ammonium. See Am- 
monii carbonas. 

Carbonate of lead. See Plumbi car- 
bonas. 

Carbonic acid gas, 226. 

how to prepare, 226. 

Carbonis sulphidum, 384. 

Caryophyllus, 548. 

Cascarilla, 230. 

Cassava, 534. 

Castoreum, 101. 

Castor oil bean, 534. 

Catechu, 89, 238. 

Cathartics, 104. 

Catheter, use of, 318. 

Caulophyllum thalictroides, 385. 

Caustics, 149, 335. 

Caustic arrows, 522. 
potassa, 53/4. 

Cauterizing pencils, 149. 

Cautery, actual, 114, 149. 
galvanic, 149. 
gas, 149. 



INDEX OF REMEDIES AND REMEDIAL MEASURES. 561 



Cauterv, thermo, 149. 
Cera, 232. 
Cerii nitras, 333. 
oxalas, 330. 
Cerium, salts of, 329. 
Chamomile. See Antheniis. 
Charcoal pencils, 149. 
Chian turpentine, 210. 
Chloral, 207, 212, 286, 290, 330, 353, 

361, 385, 421, 459, 469, 503. 
Chloralum, 414. ' 

cotton-wool, 242. 
Chlorodyne, 345. 

Chloroformum, 103, 272, 330, 356. 
Chloroformi spiritum, 448. 

linimentum, 492. 
Chromic acid. See Acidum. 
Churchill's tincture of iodine, 137. 
Cider vinegar, 202. 
Cimicifuga, 59, 77, 385. 
Cinchona, 106, 506. 
Cinnamomum, 90, 385. 
Citric acid. See Acidum. 
Civeolia levigata, 544. 
Clay, 248, 258. 
Clitoridectomy, 221. 
Cloth tents, 171. 

Clothing in the puerperal state, 300. 
Cloves, 548. 

Cocculus indicus, 59, 78, 238. 
Cochlearia tinctura, 344. 
Codeia, 78. 
Cod-liver oil, 534. 
Coffee, 90. 

Colchicum, 77, 527, 529. 
Cold, 97, 335, 463, 482, 508. 
Colocynth extract, 345. 
Collodium, 459, 549. 
Colpeurynter, 317, 406. 
Columba, 331. 

Compound licorice powder, 327. 
Compresses, 508. 
Compression of abdominal aorta, 411. 

in mammary inflamma- 
tion, 511. 

for tumors, 511. 
Condom, the, for puerperal hemor- 
, rhage, 404. 
Condy's fluid, 451. 
Conger eel soup, 533. 
Conium, 221, 277, 480, 529. 
Constipation, diet for, 345. 

pills for, 345. 
Copaiba, 157. 
Cork powder, 539. 
Corn sow-thistle, 533. 



Corn-stalk pith tents, 171. 
Coronilla juncia, 534. 
Cotton, 242. 
Creta prseparata, 546. 
Creosotum, 168, 273, 333. 
Crayons, 140, 148. 
Crocus sativus, 59, 78. 
Cubeba, 246. 
Cupping, 104, 349. 
Cupri acetas, 256. 

sulphas, 103, 239, 333. 
Cusparia cortex, 103. 
Cypripedium, 72. 

Deer balls, 533. 

De Vigo's plaster, 518. 

Diaphoresis, 350, 425. 

Diaphoretics, 428. 

Dialyzed iron, 471. 

Diet in albuminuria, 349. 

mammary tumors, 499. 

peritonitis, 479. 

vaginitis, 245. 

for agalaxia, 531, 535. 

for nursing women, 493. 

for puerperal women, 300, 326, 

345. 
to restrain the milk secretion, 

524. 
to prevent mastitis, 499. 
Digitalis, 90, 203, 221, 353, 459. 
Dilatation of cervix uteri, 219. 
os uteri, 219. 
os uteri with the finger, 
387. 
Douche, uterine, 318. 
Drainage, 47. 

Ecbolics, 322. 
Ecraseur, 192. 

m Emmet's, 192. 
Elaphomices granulatus, 533. 
Elaterium, 421. 
Electricity, 63, 335, 388, 532. 
Electrolysis, 46. 
Emetics, 105. 

in abortions, 322. 
Emmenagogues, 57. 
Enucleator, Emmet's, 192. 
Enemata, 45. 
Ergota, 60, 91, 156, 203, 272, 303, 311 

323, 385, 409, 414. 
Ergotine, 203, 303. 

suppositories, 145. 
Erigeron canadense, 414. 
Esmarch's powder, 520. 



562 INDEX TO REMEDIES AND REMEDIAL MEASURES. 



Ether, 102, 221, 333, 356. 

hypodermically, 410, 414. 

spray, 333. 
Eucalyptus, 459. 

Exercise in the puerperal state, 301. 
Extractum colocynthidis, 345. 
opii, 456. 

Faradic current, 531. 

Faradization, 531, 537. 

Feculum, 239. 

Fel bovinum, 345. 

Fennel, 534. 

Ferri ammonia, 535. 

bromidum, 221. 

carbonas, 106. 

chloridum, 414. 

chloridi tinctura, 78, 108, 239, 
398, 414, 460. 
Ferri et ammonii citras, 209. 

quinise citras, 108, 506. 

iodidum, 108. 

lactas, 535. 

mistura composita, 108. 

oxalas, 108. 

pernitras, 305. 

subcarbonas, 232. 

subsulphas, 169, 460. 

liquor, 169. 

sulphas, 108, 415, 484. 

exsiccatum, 345. 

vinum, 108. 

amarum, 107. 

valerianas, 523. 
Ferrum, 91. 

perchloridum, 86. 
redactum, 60. 
Filho's caustic, 149. 
Flagellation, 400. 
Fceniculum, 534. 
Fomentations, 405, 537. 
Food. See Diet. 
Forceps, the, 303. 
Friar's balsam, 544. 
Frigus. See Cold. 
Fucus crispus, 227. 
Fuller's earth, 544. 
Fungi, edible, 533. 

Galactogenic agents, 531. 
Galbanum, 60, 103. 
Galla, 96, 236, 347, 549. 
Gallega officinalis, 536. 
Gallega virginiana, 537. 
Galvano-cautery, 149. 
Galvanic pessary, 66. 



Galvanism, 66, 172, 205. 
Garget weed, 510. 
Gas-cautery, 149. 
Gehrung's pessaries, 189. 
Gelatine, 148. 

Gelsemium sempervirens, 386. 
Gentian-root tents, 171. 
Gentian, 162. 

Glycerina, 142, 148, 239, 550 
Glyceroles, 142, 155. 
Glycvrrhiza, 471. 
Goat r s rue, 536. 
Gossypium, 78, 323, 537. 
Goulard's extract, 270. 

lotion, 270. 
Granati radicis cortex, 239. 
Guaiacum, 79. 
Gurjun balsam, 248. 

Hamamelis, 92. 
Hsematoxyli lignum, 236. 
Heat, 97, 416, 512. 
Helleborus album, 433. 
nigrum, 78. 
Helonias, 74. 
Hip-baths, 388. 
Hodge's lever pessary, 185. 
Hop tea, 285. 

Hot bath for puerperal hemorrhage, 
404. 
fomentations, 407. 
sand-bags for puerperal hemor- 
rhage, 45. 
water douche, 242, 324. 

injections, 242. 
vaginal injections, 242. 
hand-baths, 97. 
Humulus, 285. 
Hydrargyrum, 460. 
Hydrargyri biniodidum, 204. 

chloridum corrosivum, 
204, 239, 269, 273, 340, 
436, 480. 
mite, 60, 273, 333, 550. 
iodidum rubrum, 204. 

viride, 207. 
nitras, 169. 
oxidum rubrum, 273. 
nigrum, 329. 
praecip. album, 267. 
unguentum, 44, 273. 
pernitras, 521. 
Hydrastis, 550. 
Hygiene, puerperal, 299. 
Hyoscyamus, 221, 333. 
Hypnotism, 362. 



INDEX TO REMEDIES AND REMEDIAL MEASURES. 563 



Hypophosphites, 154. 

Ice, 45, 97, 335. 
Ice bag, 97. 
Ignipuncture, 150. 
Incision in rigid os uteri, 388. 
Ingluvin, 333. 

Inhalations, oxygen, 18, 336. 
Injections, antiseptic, 372. 
astringent, 241. 
hot water, 336, 410. 
of iron, etc., into the womb, 

408, 410. 
of olive oil, 336. 
of warm water into vagina, 

336, 388. 
rectal, 336. 
vaginal, 219, 482. 
Interstitial injection of iodine, 160. 
Intra-uterine dilator, 318. 

medication, 136. 
tents, 143. 
Iodide of ammonium, 315. 

potassium. See Potassium. 
Iodinii tinctura, 144, 330, 415, 498. 
Iodinium, 44, 169, 240, 273, 333, 415, 

460. 
Iodized cotton, 158. 
phenol, 133. 
Iodoformum, 60, 169, 240, 273, 292, 550. 
Iodo-tannin, 202. 
Ipecacuanha, 92, 333, 386, 415. 
Iron swab, the, 402. 
Iron injections into the womb. See In- 
jections. 
Isinglass, 292. 
Issues, 114. 
Ivory, tents of, 171. 

Jaborandi, 323. 
Jalapa, 329. 
James' powder, 475. 
Jatropha manihot, 534. 
Juniperus, 236. 

Kiwisch's ascending douche, 319, 320. 
Krameria, 93, 236, 550. 
Kumyss, 350. 

Labarraque's solution, 476. 

Labor, antiseptic management of, 280. 

Lactopeptin, 333. 

Lactucarium, 248. 

Laminaria tents, 171. 

Laurel-water, 328. 

Lavandula, 103. 



Laxatives for puerperal women, 350. 
Leeches, 45, 63, 205, 336, 463, 482. 
Lemon for puerperal hemorrhage, 251. 

juice, 352. 
Lentils, 533. 

Ligation of varicose veins, 255. 
Linimentum belladonnse, 526. 
chloroformi, 492. 
camphoree compositum, 

529. 
saponis camphoratum, 
485, 529. 
Liquor ammonise, 465. 
iodidi, 505. 
arsenici chloridi, 97. 
calcis, 269, 540. # 
ferri subsulphatis, 201. 
hydrargyri nitratis, 105, 107, 

118, 141, 150, 179, 324. 
iodinii compositus, 101, 303. 
ferri chloridi, 47, 251. 
subsulphatis, 377. 
morphise sulphatis, 339. 
plumbi subacetatis, 241, 257, 

274, 538. 
potassae, 77, 80. 
potassee arsenitis, 78, 203. 
sodee chlorinatse, 231, 274. 
strychniae, 338. 
zinci chloridi, 246. 
Lister's antiseptic method, 311. 
Lobelia, 386, _ 
Local applications, 140. 
Local blood-letting, 173. 
Lotions, 545. 
Lubricator, 370. 
Lugol's solution, 139. 
Lupulina, 103, 221. 

Magendie's solution of morphia, 477. 
Magnesia, 333. 
Magnesii citras, 329. 

sulphas, 93. 
Maize, ergot of, 200. 
Mammary excitation, 417. 
Manipulation, 105. 
Manual pressure in labor, 382. 
Marine lint, 242. 

Marital relations in pregnancy, 301. 
Marriage as a remedy, 47, 48. 
Massage, 20, 63, 144, 497. 

of the uterus, 144, 417. 
Matico, 93. 

Mechanical dilatation of os uteri, 209 
Medical treatment of tumors, 142. 
Medicated pessaries, 227, 243, 336. 



564 INDEX OF REMEDIES AND REMEDIAL MEASURES. 



Mel, 529. 

Menthae oleum or essentia, 284. 

Mentha pulegium, 60. 

Mercury, 299, 322. 

Mesmerism, 362. 

Milk diet, 63, 349, 425, 535. 

Mineral acids, 279, 313. 

waters, 205. 
Mistletoe, 379, 416. 
Mistura potassii citratis, 293. 
Morphia, 203, 269, 314, 334, 460. 

used hypodermically, 334, 
363, 379, 427, 460. 
Morphiae murias, 520. 
Moschus, 103. 
Moss, seeds of, 547. 
Myrrha, 60. 

Narcotics, 420. 

Niemeyer's antipyretic powder, 441. 

Nipple shields, 544. 

Nitrite of amyl, 76. 

Nitrous oxide gas, 363. 

Nux vomica, 109, 286, 334. 

Nutrition. See Diet. 

Ointment, antiseptic lubricating, 370. 
Ointments, 141, 545. 
Oldham's ointment, 258. 
Oleum carbolizatum, 369. 

cadini, 268. 

cajuputi, 103. 

juniperi, 353. 

lini, 503. 

olivse, 265, 274. 

morrhuse, 534. 

ricini, 386. 

terebinthinae. See Terebinth- 
inae. 

tiglii, 353. 
Opium, 44, 290, 310, 311, 334, 386, 427, 

448, 460, 475. 
Opii extractum, 268, 328. 

tinctura, 268, 427. 
Opodeldoc, 529. 
Ovariotomy, 45, 47. 
Oxalas cerii, 330. 
Ox gall, 345. 

Oxygen inhalations, 18, 336. 
Oxytocics, 381. 

Paquelin, thermo-cautery of, 211. 
Paracelsus, elixir of, 60. 
Pasma, 141. 
Pareira brava, 279. 
Pencils, 140, 149. 
Pepsin, 334. 



[ Pessaries, 45, 173, 180. 

medicated, 143, 243, 336. 
rules for use of, 184. 
Petrolei unguentum, 520. 
Petroselinum, 510, 
Phosphorus, 428. 
Phytolacca, 503, 510. 
Pilocarpin, 323, 341. 
Pinceaux, 140. 
Pinus canadensis, 284. 
Pix liquida, 169, 274, 550. 
Pledgets, 140. 
Plugging vagina, 318, 402. 
Plumbi acetas, 93, 240, 321, 415, 502, 
510, 520. 
iodidum, 511. 
nitras, 538, 546, 550. 
subacetas, 240. 
Plumbum, 549. 
Podophyllum, 492. 
Poke root, 503. 
Position in hemorrhage, 417. 
Potassa cum calce, 44. 

fusa, 169. 
Potassae liquor, 109. 
Potassii acetas, 353. 

bicarbonas, 286. 

bitartras, 353. 

bromidum, 44, 61, 93, 204, 

221, 292, 334, 428. 
carbonas, 274. 
chloras, 94, 229, 240, 308, 321, 

529, 536. 
citras, 286. 

iodidum, 44, 204, 274, 334. 
nitras, 79, 236. 
permanganas, 209, 229, 449, 

460. 
sulpho-carbolas, 449. 
" Potion de Biviere," 329. 
Poultices, 241, 256, 482. 
Powders, 143. 

Pressure by hand in hemorrhage from 
womb, 417. 
uterine disease, 
20, 135. 
Puff powder, 270. 
Pulsatilla, 62, 79, 236, 240. 
Pulvis jacobi veri, 475. 

glycyrrhizae compositum, 471. 
Puncture of cyst, 47. 

colon, 445. 
Purgatives, 429, 463. 
Putty, antiseptic, 501. 

Quercus alba, 96, 240. 
Quiniae sulphas, 94, 240, 322, 323, 346 
386, 440, 461, 474, 539. 



INDEX OF REMEDIES AND REMEDIAL MEASURES. 565 



Quiniaa murias, 461. 

Kapid dilatation, 80. 

" Ready method " for puerperal hem- 
orrhage, 405. 

Rectal injections, 331. 

Rest, 482. 

Rhatany, extract of, 207. 

Rhamnus, 530. 

Rhei, extractum, 346. 

Rheum, 346. 

Richardson's styptic colloid, 150, 161. 

Ricinus communis, 531. 

Rufus, pills of, 59. 

Rupture of membranes to hasten la- 
bor, 381. 

Ruta graveolens, 61, 324. 

Sabina, 61, 94, 256, 322, 324. 

Sabinse oleum, 61. 

Saffron, 527. 

Salicin, 334, 462. 

Saline aperients, 274. 

Salvia, 530. 

Sanguinaria, 62. 

Santoninum, 104. 

Sapo, 347. 

Saponaria, 533. 

Saponified coal tar, 227. 

Sassafras, 157. 

Scammonium, 329. 

ScheePs method for premature labor, 

319. 
Scutellaria, 70. 
Seltzer water, 352. 
Senega, 62. 
Senna, 331. 

Separation of membranes for prema- 
ture labor, 317. 
Sinapis, 62. 
Sinapisms, 417. 
Slippery-elm bark tents, 171. 
Smith's modification of lever pes- 
sary, 188. 
Soda, chlorinated, 274. 
Sodii boras, 62, 240, 274, 324, 344. 

benzoas, 462. 

bicarbonas, 269, 325. 

bromidum, 113, 428. 

carbon as, 128, 240. 

et potassae tartras, 95. 

polysulphuretum, 269. 

salicvlas, 87, 95, 441, 462. 

sulphis, 220, 274. 

sulpho-carbolas, 455. 
Spiritus setheris, 339. 



Spiritus getheris nitrosi, 104. 

chloroformi, 338. 
ammoniae aromaticus, 338. 
Sponge tents, 97, 172, 304. < 

to dilate a rigid os uteri, 

97. 
for premature labor, 304. 
Spray, the, 365. 
Stimulants. See Whiskey. 
Stramonium, 79, 221, 347, 511. 
Strychnia, 62, 334. 
Styptic colloid, 150. 
Suberin, 538. 
Sulphuris, 109, 210, 347. 
Sumbul, 339. 
Suppository, rectal, 336. 
Suppositories, 151, 227, 243, 292, 336. 

Tabacum, 275, 335. 
Tamarindum, 87. 
Tampon de Lourcine, 235. 
alum, 265. 
for cystitis, 279. 
Tampons, medicated, 227. 
Tanacetum, 62, 274, 324. 
Tannin, 95, 277, 335, 538, 546. 

bougie, 281. 
Tar, 159. 

water, 340, 372. 
Taraxacum, 79. 
Tents, ivory, 171. 

gentian root, 171. 
laminaria, 166. 
rules for use of, 164. 
sea-tangle, 166. 
slippery-elm bark, 171. 
tupelo, 171. 
uterine, 143. 
Terebinthinse oleum, 44, 62, 196, 322, 

441, 462. 
Thea, 241. 

Thuja occidentalis, 256. 
Thymol, 251, 258. 
Thymolized clay, 248. 
Tinctura belladonnas, 339, 503. 

benzoini compositum, 538. 
camphorse composita, 339. 
cardimomi composita, 339. 
castorei, 101. 

ammoniata, 101. 
chloroformi composita, 339. 
conii, 277. 

ferri chloridi. See Ferri. 
gallse, 202. 
gentiana, 162. 
iodinii. See Iodine. 



566 



INDEX OF REMEDIES AND REMEDIAL MEASURES. 



Tinctura nucis vomicae, 286. 

opii. See Opium. 

sumbulis, 339. 

Valerianae ammoniata, 339. 
Tobacco, 275, 335, 484. 
Tormentilla, 241. 
Tragacantha, 112. 
Transfusion, 417, 429. 
Triticum repens, 280. 
Tupelo tents, 172. 
Tully's powder, 475, 491. 

Ulmus, 157. 
Unguentum cetacei, 546. 

zinci benzoatum, 545. 
Urtica, 96, 113. 
Uterine douche, 319. 

exonerants, 322. 

injections, 372. 

sedatives and lotions, 368, 
370. 
Ustilago maidis, 200, 386. 
Uva ursi, 279. 

Vaginal cataplasms, 227. 
injections, 226. 
irrigations, 226. 
suppositories, 227. 
tampons, 227. 



Valeriana, 104. 

Vaseline, 258, 349. 

Venesection, 325, 349, 388, 399, 419, 

429, 463. 
Veratria, 44, 79. 
Veratrum viride, 428, 462, 481. 
Viburnum prunifolium, 79, 96, 322. 
Vichy water, 352. 
Vienna paste, 149. 
Vinca major, 205. 
Vinegar, 202, 411. 

injections, 411. 
Viscum album, 96, 379, 416. 

Wallace's spring sponge tents, 187. 
Warburg's tincture, 440, 461. 
Warm fomentations to the head, 405. 
Whiskey, 335, 471, 547 

Zinci acetas, 241. 

bromidum, 221. 

chloridum, 246, 521, 522. 

oxidum, 96, 241, 275. 

sulphas, 96, 104, 522. 

sulpho-carbolas, 241, 258. 

valerianas, 523. 
Zingiber, 62, 331. 

tinctura, 62. 



INDEX OF DISEASES. 



567 



III. INDEX OF DISEASES. 



Abscess of breast, 497. 
"Abortion, 302. ^ 

habitual, 311. 
induction of, 315. 
threatened, 302. 
Acari vulvas, 259. 
Adenitis of breast, 499. 
Adenoma of breast, 516. 
After-pains, diagnosis of, 389. 
treatment of, 389. 
Agalactia, 531. 
Albuminuria, 348. 

of pregnancy, 348. 
Anienorrhcea, diagnosis of, 32. 
treatment of, 48. 
phthisis in, 33. 
Anaphrodisia, 212. 
Anaesthetics in labor, 355. 

when indicated, 355. 
caution in use of, 358. 
Ansemia, 105. 
Ante-flexion, 177. 
Ante-version, 173. 
Ascarides, 259. 
Ascites, 31. 
Atony of vaginal walls, 235. 

Backache, 124. 

Benign growths in breast, 516. 
Bladder, diseases of, 276. 
irritable, 285. 
tenesmus of, 288. 
paresis of, 289. 
neuralgia of, 290. 
Blood-poisoning, 439. 
Breast, abscess of, 497. 

diseases of the, 497. 

adenoma, 516. 

benign growths in, 516. 

carcinoma of, 517. 

encephaloid of, 514. 

fibroid tumors of, 519. 

fluids in, 514. 

hydatid tumors of, 519. 

hysterical, 514. 

neuralgia, of 523. 

pus in the, 514. 



Breast, sarcoma of, 514. 
scirrhus of, 514. 
tumors of, 513. 

Cancer of uterus, 206. 
of breast, 514. 
Cancroid of the os, 208. 
Carcinoma of breast, 521. 
of uterus, 206. 
cervix, 152. 
Caruncle of urethra, 255. 
Catarrhal urethritis, 283. 
Catarrh, uterine, 120. 
Cell, ovarian granular, 30. 
Cellulitis, pelvic, 470. 
Cerebral disturbance of pregnancy, 

431. _ 
Cervicitis, 146. 
Change of life, 110. 
Chapped nipples, 540. 
Chlorosis, 105. 

constipation in, 108. 
anaemia, 109. 
Climacteric, 110. 
Coccygodynia, 494. 
Colpitis, 226. 
Congestion of kidney in pregnancy, 

349. . 
Congestive dysmenorrhoea, 65. 
Constipation of pregnancy, 329, 345. 
Convalescence, puerperal, 491. 
Convulsions, puerperal, 350, 419. 
Cox-comb granulations, 202. 
Cracked nipples, 540. 
Cutaneous affections in pregnancy, 

339. 
Cystitis, 225, 276. 
Cystospasm, 290. 
Cysts, colloid, 29. 
dermoid, 29. 
of fallopian tube, 29. 
vulvo-vaginal, 257. 
serous, 519. 

Dermoid cysts, 29. 
Despondency in pregnancy, 338. 
Diabetic pruritus, 258, 262. 



568 



INDEX OF DISEASES. 



Diarrhoea in pregnancy, 345. 
Digestive derangements of pregnancy, 

344. 
Diphtheritic ulcers, 147. 
Disorders of paturition, 355. 
Displacements of uterus, 173. 
Dropsy, ovarian, 30. 
Dysmenorrhoea, 32, 64. 

congestive, 65, 75. 
spasmodic, 68. 
from general causes, 

68. 
through inefficiency, 

69. 
menorrhagic, 69. 
irregular, 69. 
rheumatic, 71. 
membranous, 65, 74, 

75. 
neuralgic, 64. 
obstructive, 65. 
ovarian atonic, 66, 78. 
Dyspareunia, 250. 
Dyspepsia of chlorosis, 106. 
ovarian, 42. 
uterine, 127. 
Dysuria, 225, 286. 

Eclampsia, puerperal, 419. 

reflex, 423. 
Eczema genitale, 258, 264. 
with diabetes, 259. 
Embolism, 465. 

Encephaloid cancer of breast, 514. 
Endo-cervicitis, 146. 
Endometritis, 120, 122. 

polyposa, 436. 
Enuresis, 225. 

Ephelides in pregnancy, 341. 
Epithelial cancer, 210. 
Erythema of the nipple, 547. 
Excoriations in vagina, 250. 
Excrescences in vagina, 256. 
Exercise during pregnancy, 301. 
Eye, affections in pregnancy, 341. 

Fallopian tubes, cysts of, 29. 
Feeble action of uterus in labor, S78. 
Foetid menstruation, 77. 

vaginal discharge, 240. 
Fever, milk, 488. 

puerperal, 439. 
Fibro-myomata, 198. 
Fibrous tumors of uterus, 193, 198. 



Flexures, uterine, 181. 
Fluor albus, 153. 
Follicular ulceration, 147. 

Galactocele, 522. 

Galactorrhea, 524. 

Genitals, pruritus of, 258. 

Gingivitis, 344. 

Glands, mammary, congestion of, 497. 

Gonorrhceal acute ovaritis, 247. 

cervicitis, 247. 

metritis, 248. 

urethritis, 247. 

vaginitis, 223, 244. 
Green sickness, 105. 
Growths, malignant, 206. 

non-malignant, 190. 
papillomatous, of vulva, 255. 
of urethra and vagina, 255. 

Habitual abortion, 302. 
Hsematoma, 467. 
Headache of pregnancy, 337. 
Heart palpitation in pregnancy, 337, 
Hemorrhage, accidental, during preg- 
nancy, 314. 

passive, 81. 

post-partum, 399. 

secondary, 
412. 

puerperal, 

uterine, 126. 
Hemorrhoids, 346. 
Herpes of vulva, 258. 

gestationis, 341. 
Hydatid tumors of the breast, 519. 
Hydrsemia of pregnancy, 352. 
Hydrosis, 446. 

Hygiene of the puerperal state, 299. 
Hypersemia of the kidneys, 350. 
Hyperplasia of the breast, 510, 519. 
Hypochondriasis of pregnancy, 338. 
Hysteria, 98. 
Hysterical breast, 514. 

Icterus gravidarum, 346. 
Impotency in women, 213. 
Impoverished blood in pregnancy, 

350. 
Incontinence of urine, 287. 
Induction of premature labor, 315. 
Inertia uteri in labor, 378. 
Insomnia of pregnancy, 337. 
Inversion of uterus, 178. 
Ischuria, 225. 



INDEX OF DISEASES. 



569 



Kidney, congested, in pregnancy, 348. 
hyperemia of, 349. 



Labor, anaesthetics in, 355. 

antiseptic management of, 364. 

atony of uterus in, 378. 

complications of, 355. 

disorders of, 355. 

premature, 315. 

rigid perineum in, 478. 

tedious, 378. 
Lacerations of cervix, 427. 
Lactation, to establish, 531. 
Leucorrhea, 172, 226, 340. 
Leptothrix vaginalis, 257. 
Life, change of, 110. 
Lochial discharge, excessive and sep- 
tic, 449. 
Lymphangitis, mammary, 511. 



Malignant growths, 206. 
Mammary abscess, 497. 
adenitis, 516. 
adenoma, 516. 
hypertrophy, 519. 
lymphangitis, 511. 
neuralgia, 523. 
sarcoma, 514. 
scirrhus, 514. 
tumors, diagnosis of, 513. 
treatment of, 515. 
Mammitis, acute, 497. 

chronic, 497. 
Mania, puerperal, 430. 
Marital relations during pregnancy, 

301. 
Mastitis, 497. 
Mastodynia, 526. 
Melancholia of pregnancy, 338. 
Menopause, 111. 
Menorrhagia, diagnosis of, 32. 
treatment of, 81. 
of menopause, 111 
Metritis, cervical, 156. 

puerperal, 475. 
Metrorrhagia, diagnosis of, 32. 
treatment of, 81. 
Milk fever, 488. 

to increase the flow of, 531. 
decrease the flow of, 526. 
tumors, 519. 
Mucous polypi, 191. 
Myomata, 198. 



Nausea of pregnancy, 325. 
Nervous cough in pregnancy, 339. 
Neuralgia in pregnancy, 338. 

of the uterine neck, 68. 
of the breast, 523. 
of ovaries, 41. 
Neuralgic dysmenorrhea, 64. 
Nipples, diseases of, 538. 
cracked, 640. 
erythema of, 547. 
fissures of, 538. 
phlegmon of, 547. 
sore, 538. 
Nymphomania, 220. 



Oedema of the vulva, 224, 264. 
Oligogalactia, 531. 
Ovarian cysts, 31. 

dropsy, 31. 

dyspepsia, 42. 

fluids, 30. 

granular cell, 30. 

hyperemia, 43. 

irritation, 41. 

neuralgia, 41. 

tumors, 30, 45. 

diagnosis, 27. 
Ovaries, diseases of, 27. 
Ovaritis, 38. 

chronic, 38. 

acute, 38. 



Pain in the right side in pregnancy, 

339. 
Pains, after, 389. 

Palpitation of heart in pregnancy, 337. 
Papillary ulceration, 158. 
Parasites, 260. 
Parametritis, 120, 132. 
Parenchymatous metritis, 126. 
Paresis of the bladder, 289. 
Parturition, complications of, 355. 
Passive hemorrhage, 81. 
Pediculi, 259, 340. 
Pelvic cellulitis, 470. 

peritonitis, 127, 470. 
Perimetritis, 120, 132. 
Peritonitis, diagnosis of, 470. 

pelvic, 470. 

puerperal, 470. 
Phlegmasia dolens, 483. 
Placenta prsevia, 375. 

inflammatory affections of, 

321. 



570 



INDEX OP DISEASES. 



Plethora, 111. 

Polypi, 190, 201. 

Polyuria, 225. ' 

Post-partum hemorrhage, 399-f 

fevers, 439. 
Pregnancy, congestion of kidney in, 
348. 
constipation of, 329, 345. 
disorders of, 299. 
albuminuria in, 348. 
clothing during, 300. 
diarrhcea of, 345. 
exercise during, 301. 
ephelides in, 341. 
food during, 301. 
headache of, 337. 
hemorrhage during, 375. 
hypochondriasis during, 

338. 
impoverished blood in, 

350. 
indigestion of, 344. 
insomnia of, 337. 
leucorrhea in, 340. 
marital relations during, 

301. 
melancholia in, 338. 
mental condition during, 

301. 
nausea of, 325. 
nervous cough in, 339. 
neuralgia in, 327. 
pain in right side in, 339. 
palpitation of heart in, 327. 
pruritus of, 339. 
sleep during, 301. 
syncope in, 327. 
vomiting of, 325. 
Premature labor, 315. 
Procidentia uteri, 182. 
Prophylaxis of puerperal eclampsia, 

350. 
Prolapsus uteri, 175, 177. 
Pruritus of diabetic, 257. 
pregnancy, 339. 
pudendahs, 258. 
vulvae, seu vaginae, 257. 
Puerperal convalescence, 491. 
eclampsia, 350, 419. 
fever, 439. 
hemorrhage, 399. 
mania, 430. 
metritis, 470. 
peritonitis, 477. 
pyaemia, 439. 
salivation, 344. 



Puerperal septicaemia, 439. 
shock, 469. 
state, hygiene of, 299. 
thrombus and embolism, 

465. 
women, laxatives for, 492. 

Eectum, pains in, 396. 
Renal congestion, 348. 
Eetention of urine, 288. 
Retroversion, 173. 
Rheumatic after-pains, 395. 
Rigid os uteri in labor, 378. 

Salivation, puerperal, 344. 

Sapraemia, 439, 446. 

Septicaemia, 439. 

Serous cysts of breast, 519. 

Sexual frigidity, 214. 

Shock, puerperal, 469. 

Sore nipples, 538. 

Sterility, 212. 

Sympathetic nervous disorders, 337. 

Syncope in pregnancy, 337. 

Tedious labor, 378. 
Thrombus, 465. 
Tuberculous amenorrhaea, 54. 
Tumors of breast, 513. 

milk, 519. 
Tympanites, 445, 478. 

Ulceration of the nipple, 538. 

of the os, 146. 
Ulcer, indolent, 146. 
inflamed, 146. 
fungous, 146. 
senile, 146. 
diphtheritic, 146. 
Ulcerations, bleeding, 147. 
Urethra, caruncle of, 255. 
diseases of, 281. 
Urethral glands, 282. 
Urethritis, 281. 

gonorrhceal, 244, 281. 
catarrhal, 283. 
Urethrocele, 291. 
Urinary disorders, 285. 
Urine, incontinence of, 287. 
Urticaria in pregnancy, 341. 
Uterine catarrh, 120. 

displacements, 173. 
dyspepsia, 127 
flexures, 178. 
inflammations, 117. 
symptoms, 116. 



INDEX OF DISEASES. 



571 



Uterine tumors, 197. 
Uterus and its annexes, diseases of, 
116. 

inversion, 178. 

occlusion of os, in labor, 384. 

Vagina, diseases of, 226. 

excoriations in, 250. 

excrescences in, 256. 
Vaginal catarrh, 226. 

discharges, foetid, 240. 

growths, 255. 

thrombus, 466. 

walls, atony of, 235. 
Vaginismus, 250. 
Vaginitis, 223, 226, 



Vaginitis, gonorrhoeal, 223, 244. 

specific, 223, 244. 
Vegetations in vagina, 256. 
Vesical irritability, 225, 285. 
irritation, 285. 
tenesmus, 225. 
Vomiting of pregnancy, 325. 
Vulva, oedema of, 224, 264. 

papillomatous growths of, 179. 
pruritus of, 257. 
Vulvitis, 261. 
Vulvo-vaginal cysts, 257. 

Warts in vagina, 256. 
Whites, the, 153. 
Womb. See Uterus, 153. 



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3 



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"MODERN THERAPEUTICS" 

SERIES. 
I. MODERN MEDICAL THERAPEUTICS. 

A Compendium of Recent Formulae and Specific Therapeutical Directions from the 
practice of eminent contemporary physicians, American and foreign. By Geo. H. 
Napheys, a.m., m.d, Seventh Edition. One volume, 8vo, pp. 607. Price, cloth, $4.00; 
sheep, $5.00. 

H. MODERN SURGICAL THERAPEUTICS. 

A Compendium of Current Formulae, Approved Dressings and Specific Methods for 
the Treatment of Surgical Diseases and Injuries. By Geo. H. Napheys, a.m., m.d. 
Seventh Edition (1881). One volume, 8vo, pp. 608. Price, cloth, $4.00; sheep, $5.00. 

HI. THERAPEUTICS of GYNECOLOGY and OBSTETRICS. 

Edited by William B. Atkinson, m.d., etc. Second Edition, Greatly Enlarged (1881). 
One vol., 8vo. Price, cloth, $4.00; sheep, $5.0<\ 



This Series of Therapeutics has been recognized by the Medical Press, both of England 
and the United States, to be the most practically valuable to the physician of any which is 
now in the market. The following hints as to its plan will give some idea of its exceeding 
usefulness: — 

IN THE MEDICAL THERAPEUTICS the total number of authors quoted is 723, and the 
precise formulae given 1124. Each disease is taken up and its treatment presented according 
to the latest and best authorities in Europe and this country. Many of the directions and 
formulae have never been published elsewhere. A " Resume of Remedies " follows each dis- 
ease, showing all the drugs which have a well-merited reputation in the therapeutics of the 
complaint. Nor are the descriptions confined to drugs only, but every therapeutic resource in 
a disease is specified, including electricity, bathing, mineral waters, external applications, 
climate, diet, sanitation, etc., etc. 

IN THE SURGrlCAI^ THERAPEUTICS the number of authors quoted is 712 ; the number 
of their prescriptions given, 1021. The special object of this work is to set forth the medical 
aspect of Surgery, to collect in one volume the Therapeutics of Surgery, the formulae and 
medical treatment of Surgical diseases of the most eminent surgeons. 

Of the subjects treated may be mentioned : — 

The types and treatment of Inflammation, general and local anaesthetics and anaesthetic mix- 
tures, full and minute directions for the Treatment of Wounds, by Lister's Antiseptic Method ; 
Porcher and Wood's " Open treatment" ; Gamgee's " anhydrous dressings " ; Guerin's raw 
cotton dressings ; water dressings ; Dolbeau's alcohol dressings ; Spence's boracic acid dress- 
ings ; Hewson's earth dressings ; Polli's sulphite dressings ; and many others. 

Bartholow's, Hyatt's and Holmes' methods with erysipelas. Dr. Garretson's specific 
combination. 

Hemorrhage; Richardson's styptic colloid, styptic lint, wool, cotton and collodion. Styp- 
tic mixtures of Pancoast, Pagliari, Martin, etc. Methods of torsion, and pressure, and cold. 

The immediate and later treatment of primary and secondary shock, by Brunton, Hood, 
Fothergill, Smith, Gross, Fuller, Holmes, etc. 

The use of physostigma, aconite, atropia, strychnia, etc., in tetanus. Weir Mitchell on 
traumatic paralysis and neuralgia. 

The latest views of the German surgeons, Esmarch, Stromeyer, and Billroth, on gunshot 
wounds. 

The best remedies in hydrophobia. Halford's ammonia treatment'of snake bites. 

Numerous applications for burns, scalds, frostbites, bed sores, carbuncles and boils. 

Syme's treatment of indolent ulcers. Villate's solution for caries. Morton's improved 
treatment of spina bifida. Massage in paralysis, sprains, etc. Squire's method with naevus. 

Miner, Vallette, Colles and others, on varicose veins. Various authors on caries of the 
teeth, pharyngitis and tonsillitis. Ruppaner's London Paste, for enlarged tonsils. 

Pancoast' s and Heaton's new method for the radical cure of hernia by subcutaneous injec- 
tions. The carbolic acid treatment of hemorrhoids. 

Impotence, masturbation and spermatorrhoea occupy thirty pages, a monograph in itself, 
full of suggestions. 



The chapter on lesions of the organs of special sense includes the nose, eye, and ear, ds 
oza?na, epistaxis, rhinitis, conjunctival diseases, iritis, styes, wounds of the eye, otorrhcea, 
tinnitus, etc. 

Under new growths are given Mackenzie and others on goitre, and the medical and 
local treatment of fatty tumors, polypi, warts, corns, etc. ; and twenty-four pages are 
devoted to cancer, giving Williams' bromine treatment, the arsenical cure of Marsden and 
Esmarch, Maissoneuve ; s caustic arrows, Michel's sulphuric acid paste, etc., and the famous 
,k cancer salves " of Landolfi, Fell, Payne, Bright, etc. 

A chapter is given to the treatment of scrofula, as recommended by Gross, Toland, Savory, J. 
L. Smith, Porcher, etc., including scrofulous ophthalmia, ulcers, glandular enlargement, etc. 

The volume closes with chapters on the therapeutics of skin diseases, gonorrhoea and syphi- 
lis, in the last of which Keyes' tonic treatment is described. The formulae for gonorrhoea are 
especially numerous. 

Especial pains has been taken to give carefully the uses and indications of recently intro- 
duced remedies, such as chrysophanic acid, terebene, the salicylates, hamamelis, dioscorein, 
daturia, eserin, grindelia, hydrobromic acid, etc. 

THE THERAPEUTICS OF GYNECOLOGY AND OBSTETRICS 

Presents a careful and exhaustive review and estimate of the therapeutical resources of the 
gynaecologist and obstetrician. The number of authors quoted is 422. The number of for- 
mulas presented about 500. 

It is divided into two parts as follows : — 

PART I. GYNECOLOGICAL THERAPEUTICS. Chapter I.— Diseases of the Ovaries, Dis- 
orders of Menstruation and General Diseases. Chapter II. — Diseases of the Uterus and its 
Annexes. Chapter III. — Diseases of the Vagina, Urethra and Bladder. 

PART II. OBSTETRICAL THERAPEUTICS. Chapter I.— The Disorders of Pregnancy. 
Chapter II. — The Complications, Disorders and Sequelae of Parturition. Chapter III. — Dis- 
eases of the Mammary Glands and of Lactation. 

The therapeutics of each disease or disorder is given, from the latest American, English, 
French, German, and Italian authorities ; and the effort is constantly made to represent- 
accurately the directions of the most eminent clinical teachers, both as given in their works 
and in their contributions to periodical literature. 

The following are mentioned as a few of the many interesting subjects presented in this 
volume : — 

Chrobak (of Vienna) on the general medical treatment of the Diseases of women. 
Balneo-therapy in diseases of women. 

Prof. Simpson's scheme for making a gynecological examination. Synopses of Diag- 
nostic Points on diseases of women. 

The methods of treating ovaritis, as practiced by De Sinety (Paris), Olshausen (Halle), 
Duncan, Hewitt, Fothergill and Tilt (London), Tait (Birmingham). Peaslee, Cutter, 
De Sinety, Boinet and Courty on the medical treatment of Ovarian Tumors.' 

Amenorrhea, Dysmenorrhea, Menorrhagia, etc., by various authors. Chlorosis and Hys- 
teria. Fonnsagrives, Sussdorf, Quisac and others on the diseases of the Climacteric Epoch. 

Endo-, Peri- and Para-metritis, as treated by Playfair, Atthill, Byford, DeSinety, Hick- 
inbotham, etc. Battey's iodized phenol. Intra- uterine medication. Leblond's caustic 
pencils. Tents crayons, pledgets, capsules, powders and medicated pessaries, used in 
gynecology. Displacements. Benign and malignant growths. Medical treatment of 
uterine Cancer (by Williams, Clay, De Sinety, Lawrence, Westmoreland, etc). Sterility : 
Anaphrodisia ; Nymphomania. 

Specific and non-specific Vaginitis ; differential diagnosis and treatment. Irritable 
Bladder, Cystitis, vaginal growths, Pruritus vulvae, etc. 

In the Obstetrical Part will be found — 

Simpson's plan for Case-taking in Midwifery. MacDonald, Parvin, Meadows and others 
on the management and induction of abortion. Barbiglia, Sims, Copeman, etc., on preg- 
nancy vomiting. Legg^ on Icterus Gravidarum. The cutaneous affections of Pregnancy. _ 

An entirely new section on Antiseptics in Labor, with the most recent views and practice 
of Fritsch, Stadfeldt, Weber, Zweifel, Hofmeier, etc., on this important subject.^ Uterine 
post-petrtum injections receive special attention. Anaesthetics in labor are fully discussed. 

The management of Tedious Labor, Placenta Prae via and After Pains is given at lengthy 
from such writers as Albert H. Smith, Isaac E. Taylor, E. W. King, Henry L. Horton of 
this country, and Chantreuil, Meadows, Leishman, Ranking, etc., of Europe. The sections 
on Post-partum Hemorrhage, Puerperal Eclampsia, and especially that on Puerperal Fever, 
are exhaustive. In the last mentioned, the new and invaluable principles of the antiseptic 
treatment are fully described, as practiced by Amann, Schroder, Duncan, etc. 

Milk Fever, Phlegmasia Dolens, Coccygodynia, Puerperal Insanity, Mammary tumors and 
abscess, diseases of the nipples, etc. , are discussed in the same manner. 

In the preparation of this Second Edition, besides the obstetrical and gynecological peri- 
odicals of all countries, all the recent important works published on these branches in France 
and Germany have been consulted, as those by Billroth, Amann, Chrobak, Winckel, Mayrhofer, 
Olshausen, Leblond, De Sinety, etc., etc. 



8 

Each book has a complete Table of Contents, and three elaborate indexes, one of Authors, 
a second of Remedies and Remedial Measures, and a third of Diseases. It has been a special 
aim of the author and editors to include all the latest approved new remedies, the most fa- 
mous combinations, and, in fact, all the " points" or " wrinkles " of modern therapeutics, so 
that with these volumes on his table the practitioner in the most remote settlement, or he 
whose time is most over-occupied, can at once familiarize himself with the latest acquisitions 
of the therapeutical art. 

OPINIONS OF THE PRESS AND OF READERS 

FROM ENGLISH MEDICAL JOURNALS. 

"After a close scrutiny we have come to the conclusion that the thorough revision given to the seventh edition of 
this book (the Medical Thekapeutics) has made it the most valuable work on treatment a practitioner can possicly 
procure. It is abreast of the latest views." — Medical Press and Circular (London), September, 1880. 

" This work is well conceived and carefully executed, and will be of very great service to the practitioner." — The 
Lancet, London, August, 1879. 

" This is a useful and interesting book, which no one can take up without finding something he did not know before." 

FROM AMERICAN MEDICAL JOURNALS. 

" Napheys' Therapeutics is a work with which the profession has become well acquainted, through its former editions. 
The present edition is much changed from the last. Many additions have been made, gathered from recent sources, 
and, in fact, the work has bern thoroughly revised. As a means of familiarizing with the methods and remedies em- 
ployed in different parts of the world by leading practitioners, no other book is equal to it." — Pacific Medical Journal, 
1380. 

" Divested as they are of all that is not strictly practical, containing such information as is of every day requirement, 
and containing no useless verbiage, these books are such as the general practitioner particularly will find of great assist- 
ance." — Michigan Medical Neivs, 1880. 

' ; An admirable compendium * * * an eminently practical work." — Michigan Medical News. 

"A unique book ; it shows vast labor on the part of the author." — St. Louis Clinical Record. 

"A very valuable aid to practice, indeed, almost indispensable." — St. Louis Medical and Surgical Journal. 

" Cannot fail to help almost any practitioner." — Louisville American Practitioner. 

" It is eminently a practical work." — Louisville Medical News. i 

"In no other work can the practitioner learn so easily the favorite medicines in treating disease, and the best 
methods in compounding them." — Louisville American Medical Bi-weekly. 

"Of the utmost practical utility to every physician and surgeon. They are all, and more, than the editor claims for 
thorn." — Richmond, Virginia, Medical 3Ionlhly. 

"Invaluable to every practicing physician. —^New York Medical Record. 

" All that is in the book is good." — Philadelphia Medical Times. 

"We cordially recommend these books."— New Orleans Medical and Surgical Journal. 

The following opinions refer to the Therapeutics of Gynecology axd Obstetrics : — 

" This book is one which the general practitioner will find of great assistance to him." — Michigan Medical News. 
" It is concise and intensely practical, and we cordially commend it, both to the profession and the student." — Hie 
Therapeutic Gazette. 

• " We consider it superior to either one of the other volumes." — Cincinnati Medical News. 
"We recommend it, as filling a general want." — Atlanta Medical and Surgical Journal. 

OPINIONS OF READERS. 

From many private letters, testifying to the merits of this work, we quote, with permission, 
the following : — 

Dr. J. G. Bacon, Saratoga, N. Y. " 'Napheys' Therapeutics ' is ahead of anything in tho market, for the working phy- 
sician." 

Dr. R. L. Moore, Spring Valley, Minn. " The ' Therapeutics ' has proved of great practical value to me." 

Dr. Eli Fox, Mohawk, N. Y. " Cannot fail to prove most acceptable to the entiro profession." 

Dr.R. M. Foster, Gallatin, Tenn. "Of unlimited value to the practitioner." 

Dr. V. II. LTarrison, Clarkton^ Mo. " The best work of the class I have ever seen." 

Dr. I. F. Scott, Schoharie, N. Y. " The books are all that could be desired." 

Dr. 0. F. Remick, Butler, Mo. " I cannot too highly commend these works." 

Dr. T. H. Buecking, Quincy, III. " It is invaluable." 

Dr. A. Van Derver, Albany. "I have found Napheys' ' Therapeutics ' safe, reliable, and thoroughly up in modern 
medicine." 

Dr. I. M. Biaelow, Albany. " The work is most discreetly compiled, and without a peer ; it is an invaluaLle therapeu- 
tic counsellor." 

Dr. J. C. Manson, Pittsfield, Me. "I use them more than any other books -in my library." 

Dr. II. A. Spencer, Erie, Pa. " They are the most practical and useful books I ever met with." 

OFFER. — The publishers offer to send either volume of the above work on receipt 
of the price, on examination ; if not satisfied, the purchaser has the privilege of mailing it 
hack within twenty-four hours from receiving it, and the price will be refunded to him. He 
will thus risk oniy the postage, which is 24 cents. 

We give on the opposite page a " Specimen Page " of the Medical Therapeutics, showing 
the size and style of the work. 



OF THE 

Modern Therapeutics Series. 



DIARRHCEA — ACUTE AND CHRONIC. 281 

552. R . Acidi nitro-muriatici, f. 3 iss. 

Tincturae opii, tt\,xl. 

Syrupi, f. 5 ss. 

Aquae, adf.^iv. M. 

A tablespoonful in water, four times a day. 

DRS. BURKART AND RICKER, STUTTGART, GERMANY. 

These writers have lately called attention to what they deem the 
extraordinary powers of coto bark, and its active principle, cotoin, in 
diarrhoea, intestinal catarrh, and dysenteric disease. The remedy was 
employed in the form of powder, tincture, and the active principle, cotoin. 
The taste of the powdered bark and tincture is particularly disagree- 
able, increasing the flow of the saliva in a marked degree. In mod- 
erate doses, they generally produce a burning sensation in the stomach, 
and, very frequently, eructations and vomiting, making both these 
forms of exhibition extremely undesirable. The employment of 
cotoin is free from these objections, for very small doses produce the 
desired effect, without inducing secondary disturbances or disagreeable 
6ensations of any kind. 

553. R. Cotoinse, gr j. 

Aquae destillatae, f.^ iv. 

Alcoholis, gtt. x. 

Syrupi, f.^j. M. 

A tablespoonful every hour. 

Some of the cases were of long standing, some were severe attacks 
of cholera morbus, and others had been but little benefited by tannin, 
opium, or lead acetate. The above mixture produced speedy improve- 
ment — generally in a few hours — and complete recovery in from twelve 
hours to six days. 

DR. EDWARD R. SQUIBB, BROOKLYN. 

The following is a favorite prescription of this physician, in diar- 
rhoea: 

554. R . Tincturae opii, 

Tincturae camphorae, 

Tincturae capsici, aa £*?j; 

Chloroformi purificati, f-o iij- 

Alcoholis, adf.Jv. M. 

A teaspoonful as required. 

RESUME OF REMEDIES. 

ACUTE DIARRHCEA. 

Camphor is regarded by Dr. Ringer as one of the most efficacious of remedies in 
summer diarrhoea, but it must be employed at the very commencement of 



10 



THE PRINCIPLES AND METHODS 



OF 



THERAPEUTICS. 

BY ADOLPHE GTJDBLiER, MI.X>., 

Professor of Therapeutics in the Faculty of Medicine, Paris, Member of the Academy of Medicine, Physician to the 
Beaujon Hospital, etc. Translated by M. J. Halloran, M.D., etc. 1 vol., 8vo, pp. 445. Heavy tinted paper. 
Bound in Half Morocco, muslin sides. Price $4.00. 



Among the scientific therapeutists of the age. Professor Gubler stood in the front rank. 
This work is a translation of his lectures in this specialty, and is rich in practical informa- 
tion and profound suggestions. There is no work on the principles of Therapeutics which 
will better repay close reading. It is a new book, having first appeared this year. 



OPINIONS OF THE PRESS. 



"This book is replete with practical points 
in regard to the proper method of adminis- 
tering remedial agents. The practitioner 
will find in its pages much matter that he is 
in daily need of, and which perhaps he has 
sought for in vain in works treating of thera- 
peutics from a different point of view. It will 
not fail to take its place as a standard work. ' ' 
— The Medical Gazette, April, 1881. 

1 ' This work is sui generis. It will pay the 
general practitioner to get it and read it ; it 
will be found very attractive and highly 
profitable." — The Country Practitioner, 
March, 1881. 

' ' The aim of this work is to represent, from 
the latest acquisitions of science and by the 
aid of the most careful instructions — first, the 
methods which can be most effectively em- 
ployed in the administration of remedial 
agents, and next the principles or processes 
by which their remedial action is exerted on 
the human economy. This is very clearly 
carried out to its fullest aim, every obstacle 
being surmounted with great care. ■ This 
Avork is gotten up very handsomely, doing fall 
credit to the publisher' s taste. ' ' — The Southern 
Practitioner, April, 1881. 

u It is a book of immense value to the edu- 
cated physician, who desires to know more 
than the simple fact that a certain drug will 
produce certain effects, and whose inquiring 
mind has often suggested to him the question: 
' How are these effects produced ; why does 
one medicine seek out the nervous system, 
another the heart, a third act as an alterative, 
and so on ?' In this volume he will find his 
question answered, to the best of human 
ability. The author's explanation of the ac- 
tion of alteratives is particularly interesting. 
Professor Gubler was a worthy disciple of 

On the opposite page we give a "specimen page' 
size and type. 



the great Trousseau, and the opinions given in 
this work bear the stamp of high and un- 
doubted authority." — The American Special- 
ist, April, 1881. 

" The work, more than any other of the 
kind with which we are acquainted, is a sci- 
ence of therapeutics. The author has aimed 
to unfold principles. The student who loves 
to be able to give a reason for all that he does 
in the application of remedies to disease will 
find it a work just to his mind." — Cincinnati 
Medical News, March, 1881. 

' 'This work is unique in design. The reader 
who expects to find it like most books upon 
this subject will be agreeably disappointed. 
The author approaches his subject in a differ- 
ent manner from the majority of writers, and 
this very fact constitutes one of the charms 
of the work. The reader will gain a better 
notion of its scope by a selection from the 
table of contents. The first four chapters 
are devoted to a consideration of general 
therapeutics, in which the composition, 
properties, etc., of medicinal substances are 
discussed. Then follow nine or ten chapters 
on avenues for the introduction of medica- 
ments, elaborate and careful description of 
the methods by inhalation, fumigations, aero- 
therapy, atomization of liquids, by absorp- 
tion from open wounds, baths, by hypoder- 
mic injection, acupuncture, transfusion. A 
few chapters are devoted to arsenic, and the 
last chapters to the elimination of medica- 
ments, accumulation of remedial agents, force 
of habit, antagonism between morphine and 
atropine, and conditions affecting medicinal 
action. We think it a book at once readable 
and instructive. It has been excellently 
translated. "We would urge all physicians to 
obtain it. — Nashville Journal of Medicine and 
Surgery, April, 1881. 

of Gubler' s Therapeutics, showing the 



11 



OF 



GUBLER'S THERAPEUTICS 



AEROTHERAPATHY. ATOMIZATION OF LIQUIDS. Ill 

is, that it cannot fail to be of benefit to those suffering from 
tubercles to breathe the air on high table-lands. 

It is very possible that under the conditions in which the 
high table-lands of Mexico are, there may be no sufferers from 
tubercles there. With regard to anaemia, I recall a conversation 
which I had with a distinguished personage who has lived on the 
high table-land above Quito, at an altitude of 4200 metres. 
While there he had to put up with a great many privations, 
but this did not prevent him from taking daily observations, 
the results of which he sent to the Paris Academy of Sciences. 
I questioned him for the purpose of learning if at Antizana 
and at Quito (an altitude of 2200 metres) there were habitual 
anaemics. He replied that, on the contrary, the population was 
in splendid physical condition, and that the inhabitants were 
very vigorous. You see that there are reservations to be made 
as to the influence of altitude upon the development of anaemia. 
Hence it were presumption at present to infer a sort of antago- 
nism between anaemia and tuberculosis. 

Inhalations of oxygen have long been in use. At the 
end of the last century, following Fourcroy's example, they 
were used against asthma. This malady chiefly presenting diffi- 
culty of breathing, seemed to call for either condensed air or 
pure oxygen, since the purpose was to supply air in excess to the 
patient. In Laennec's time, oxygen was tried against asthma, 
but without success. In other cases where better results were 
obtained, it is evident they had not to contend against asthma, but 
against real dyspnoea, or, if you prefer, against asthma sympto- 
matic of a lesion of the heart, or of other affections of the 
thoracic organs. Oxygen does not suit asthmatics, and, for my 
part, I have never seen it successfully used against asthma, prop- 
erly so called. 

After the negative results obtained by Laennec, oxygen inhala- 
tions fell into disuse. Afterwards, the experiments made by 
Regnault and Reiset have again called attention to this gas, and 
it has once more come into favor. Besides, manufacturers and 
chemists have supplied apparatus allowing inhalations to be 



12 

DIFFERENTIAL DIAGNOSIS: 

A MANUAL OF THE COMPARATIVE SEMEIOLOGY OF THE MORE 

IMPORTANT DISEASES, 
By F. T>E1 HAVILLAND HAJL,I1,, M. D., 

Assistant Physician to the Westminster Hospital, London. 

Second American Edition, with Extensive Additions. 

EDITED BY FRANK WOODBURY, M.D. 

One Volume, Svo., pp. 205. Printed on handsome tinted paper; bound in English pebbled cloth, 

with beveled boards. Price $2.00. 



Dr. Hall's work has received the highest encomiums from the English medical 
press, for its lucid arrangement, completeness and accuracy. He himself is known 
in London as a practitioner of great skill, and an unusually successful medical 
teacher. 

Most of the diseases which may be confounded are presented in comparative 
tables, setting forth their distinctive characteristics in the clearest possible light, and 
thus greatly facilitating their prompt diagnosis. 

OPINIONS OF THE PRESS. 

The British Medical Journal says: "This is not of the type of books brought 
out by ' grinders.' The tables it contains are invaluable aids by the bedside, enabling 
the student and practitioner readily to compare signs met with in disease." 

The North Carolina Medical Journal says : " The tabular method of comparing 
symptoms is well utilized. Very many valuable diagnostic formulae are brought 
together." 

The Atlanta Medical Journal says : "The comparative symptoms are given in 
a very satisfactory manner. The work will afford valuable aid to practitioners." 

The Boston Medical and Surgical Journal, March 6th, 1877, says : " The physi- 
cal signs and the symptoms of the various affections are arranged in tabular form for 
convenient reference, and the facility thus afforded for comparison and discrimination 
enables this manual to supply a want often experienced in more elaborate treatises." 

The New Orleans Medical and Surgical Journal says: "The plan of the work 
we regard as highly commendable for its convenience of reference and the precision 
of which it is capable." 

THE DISEASES OF LITE STOCK, 

Including Horses, Cattle, Sheep and Swine. 

Containing a description of all the usual diseases to which these animals are liable, and the 

most successful treatment of American, English and European Veterinariajis. 

By LLOYD V. TELLOR, M. D. 1 vol., 8vo., pp. 474. Price, Cloth, $2.50. 

. 

This work is divided into four parts, as follows : I. General Principles of Veteri- 
nary Medicine. II. Diseases of the Horse. III. Diseases of Cattle, Sheep and 
Swine. IV. Hygiene and Medicines. 

The author of this work is a regular physician, whose practice in the country 
has led him to study the diseases of domestic animals, and we can point to it as the 
first and only book, by an American physician, which describes, with scientific 
accuracy, and yet in plain language, these common and important maladies. 



13 



LESSONS IN GYNECOLOGY. 

By WM. GOODELL, A.M., M.D., 

Professor of Clinical Gynecology in the University of Pennsylvania. 

WITH NUMEROUS ILLUSTRATIONS. 

SECOND EDITION. 

THOROUGHLY REVISED and CONSIDERABLY ENLARGED. 

One Volume, 8to. Price— Cloth, $4; Sheep, $4.50. 



The Second Edition of this able work was demanded within three months from the 
publication of the first. The author has, however, taken the time to give it a very careful 
revision, and has added a large amount of new and unpublished material. The medical 
press, both in this country and Great Britain, has been unanimous in bestowing on this work 
the warmest praise. We have space for but a few of the very many encomiums it has received. 



The Dublin Journal of Medical Science, 
Dec. 1880, devotes twelve pages to an analy- 
sis of its contents, concluding with the fol- 
lowing words: " We cordially welcome this 
volume as a most valuable addition to gyne- 
cological literature, replete with sound infor- 
mation, given in that simple clinical style 
which makes it all the more acceptable to the 
student or busy practitioner.*' 

The Glasgow Medical Journal, Nov. 1880, 
at the close of a review ten pages in length, 
says: "We cannot but commend the book 
to those who are or who wish to become 
gynecologists." 

The London Medical Times and Gazette, 
Nov. 6, 1880, expresses itself: "This vol- 
ume must take a high rank among works upon 



the subject of which it treats. It presents 
striking and rare merits. We advise our 
readers to study it." 

After a lengthy analysis, the Canada Medi- 
cal and Surgical Journal adds : " We here 
conclude our notice of this remarkable book, 
by merely saying that every gynecologist 
must read it, and exceedingly pleasant read- 
ing he will find it to be." 

In a similar strain the Canadian Jour- 
nal of Medical Science, Feb. 1881, writes: 
" Throughout the whole work there runs a 
vein of sound common sense and practical 
wisdom. As a book of the kind — and the 
kind is a good one for a general practitioner 
— we know of none better. Get it as soon as 
possible, and we feel sure you will read it."' 



CONTENTS. 

Lesson I. Gynecological Instruments. II. Modes of Examination. III. Caruncle, and 
other Affections of the Female Urethra. IV. Vesical Diseases of Women. V. Fistulse of 
the Female Genital Organs. VI. Closure of the Vulva for Incurable Vesico-vaginal Fistulae 
— Tumors of the Vulva. VII. Some Affections of the Vulva and Surrounding Parts. 
VIII. On Lacerations of the Perineum. IX. Secondary Operation for Laceration of the 
Female Perineum. X. Metritis and Endometritis, Acute and Chronic. XL Local and 
Constitutional Treatment for Chronic Metritis and Endometritis. XII. Retroversions and 
Retroflexions of the Womb. XIII. Anteversions and Anteflexions of the Womb. XIV. 
Dilatation of Cervical Canal ; Rapid Dilatation ; Tents. XV. On the Use of the Closed Lever 
Pessary, and of the Infra-uterine Stem Pessary. XVI. Different Kinds of Pessaries ; 
Abdominal Supporters. XVII. Prolapse of the Womb. XVIII. Prolapse of the 
Womb continued. XIX. Laceration of the Cervix Uteri. XX. Cancer of the Womb. 
XXI. Vegetations of the Endometrium. XXII. Polypus of the Womb. XXIII. Fi- 
broid Tumors of the Womb. XXIV. Treatment of Fibroid Tumors of the Womb. 
XXV. Ovaritis and Prolapse of the Ovaries. XXVI. Spaying for Fibroid Tumors, and 
other Diseases of the Womb. XXVII. Ovarian Cysts. XXVIII. Ovariotomy by Ab- 
dominal Section. XXIX. Vaginal Ovariotomy. XXX. Nerve-tire and Womb -Ills. 
XXXI. The Prevention of Uterine Disorders. XXXII. The Sexual Relations as Causes 
of Uterine Disorders. XXXIII. The Relation which Faulty Closet Accommodations Bear 
to the Diseases of Women. 



14 

sxstts zar cteb 
OBSTETRIC PROCEDURE. 

BY WILLIAM B. ATKINSON, A. M., M. D., 

Lecturer on Diseases of Children, at the Jefferson Medical College. Physician to the 

Department of Obstetrics and Diseases of Children, Howard 

Hospital, Philadelphia, Penna. 



SECOND EDITION. ENTIRELY RE-WRITTEN AND ENLARGED. 

ISmo., CLOTH. PRICE, ^l.OO. 



" The charmingly informal style of the author renders the reading of the mono- 
graph a positive pleasure. Conscientiously we feel that we are working in the inter- 
ests of both physician and patient when we say to all who do not own it now, order 
at once a copy of these Hints for your own use." — The Detroit Lancet, July, 1879. 

" The author, a teacher of experience, treats his subjects in a way to make it 
especially useful to the student, but not to the student alone." — The Richmond and 
.Louisville Medical Journal, June, 1879. 

" Dr. Atkinson fully appreciates the vast importance of the obstetric art in both 
its immediate and remote effects on mothers and children, as well as the reputation 
of the physician, and, in this interesting little work, gives valuable hints, which are 
intended to guide us in the management of women before, during and after the ter- 
mination of labor." — Canada Journal of Medical Science, July, 1879. 

"The many valuable points cited, the practical manner in which they are 
stated, together with the sound views of practice enunciated, make this little mono- 
graph truly valuable." — The Southern Practitioner, January, 1879. 

"It is the gist of the obstetric art in convenient form, and will serve to refresh 
the practitioner's mind in any case pertaining thereto." — Maryland Medical Jour- 
nal, June, 1879. 

A Biographical Dictionary of Contemporary 
American Physicians and Surgeons. 

SECOND EDITION. 

Edited by WM. B. ATKINSON, M. D., 

Permanent Secretary of the American Medical Association, and of the Pennsylvania State Medical 
Society ; Lecturer on Diseases of Children at the Jeff&rson Medical College, etc. 



One Volume, Royal Octavo, Double Columns, 780 Pages, on Fine, Tinted Paper. 



Price, in extra cloth, beveled edges, $4.00; in full leather, $5.00. 



This really monumental work, the fruit of enormous labor and outlay, contains 
the biographical sketches of more than twenty-eight hundred contemporary regular 
physicians of the United States, prepared from materials in most instances furnished 
by themselves, and hence entirely trustworthy. Indexes of names and places are 
appended. The effort has been made to embrace all who have visibly contributed 
to the advancement of medical science in all parts of the Union, and the volume 
presents a mass of most valuable historical, biographical and scientific material. 

JS^§* A few copies of the First Edition, with nearly a hundred fine steel engrav- 



15 

COMPENDIUM OF 

MICROSCOPICAL TECHNOLOGY. 

A GUIDE TO PHYSICIANS AND STUDENTS IN THE USE OF THE MICROSCOPE AND 
IN THE PREPARATION OF HISTOLOGICAL AND PATHOLOGICAL SPECIMENS. 

BY CARL SEILER, M.D., 

Late Director of the Microscopical and Biological Section of Natural Sciences of Philadelphia ; 

Curator of the Pathological Society ; Pathologist and Microscopist to the 

Presbyterian Hospital, etc., etc. 

Illustrated, One Yolimie, 8to. Cloth, pp. 111. Price $1.00. 



This manual has met with very great favor, and is written with the special aim of quali- 
fying physicians to use the microscope skillfully in diagnosis, wiU*out wasting time on the 
needless prolixity of large volumes. A comparative Table of Tumors is added, so arranged as 
to enable the reader to compare at a glance the macroscopic, microscopic and clinical charac- 
ters of pathological growths. 

The reception this volume has met with may be seen from the following 

NOTICES OF THE PRESS. 

" No worker with the microscope, whether he be professional or amateur, can afford to be without Dr. Seiler's 
book." — Louisville Medical News. 

" There is a great deal of practical value in this book. The reader feels that the directions are the results of 
practical experience. "We can heartily commend it, on account of the justice, clearness and minuteness of the direc- 
tions."' — Boston Medical and Surgical Journal, March, 1880. 

" From a careful examination of this book, we are convinced that it will be a real help in histological study." — 
Detroit Lancet. 

"It needs no urging upon our part to push forward this book, as its usefulness cannot fail to be seen by every one 
into whose possession it comes." — Southern Practitioner. 

" "We have long been waiting for a book of this kind. It contains just the information needed." — St. Louis Med, 
and Surg. Journal. 

" While there are numerous text-books on this subject, there is none so well adapted as this to the needs of stu- 
dents and general practitioners." — Nashville Journal of Medicine and Surgery, Feb., 1881. 

" It is well illustrated and well written." — Maryland Med. Journal, Feb.. 1881. 

" The author has supplied a real want in presenting this compendium. It contains the tried processes of an 
expert." — Cincinnati Lancet and Observer. 

" It is a book that the practical microscopist cannot afford to be without."— The 3Iicroscope, April, 1981 . 

HYDROPHOBIA? 

A MONOGRAPH. 

BY HORATIO R. BIGELOW, M.D., ETC. 

1 vol., 8vo, pp. 156. Price $1.00. 



A thorough and searching study of this terrible disease, its history, causes, prevention 
and treatment. Cannot fail to be valuable to the profession. 

NOTICES OF THE PRESS. 

"This interesting subject is so meagerly discussed in the text-books, that a b. ok embodying the literature on the 
subject of hydrophobia should be welcomed by all Dr. Bigelow's aim has been to condense into convenient size the 
history of tho disease, to state succinctly the various theories regarding it, and to give the latest views of its morbid 
anatomy and treatment."— The Southern Clinic, May, 1881. 



16 

A MANUAL OF 

EXAMINATION OF THE EYES 

BY DR. E. LANDOLT. 

Translated by SWAN M. BTTRISrJETT, IM.TD., Etc. 

REVISED AJSTJD ENLARGED BY TELE A JIT ETO JR. 

i Vol., 8vo, pp. 307. "With numerous Illustrations and a large Chart. Price, Cloth, $2.00, 



This work, by one of the most distinguished European teachers, will be found the very- 
best in the language on the subject of which it treats. It has received the highest praise in 
Europe and this country. 

NOTICES OF THE PEESS. 

"This book is one that can be recommended to the doctor and student, with the acsurance that it will meet every 
demand. " — Louisville Medical News. 

"A most admirable and complete exposg of our means and methods for making a thorough scientific examination 
of the human eye." — Chicago Medical Journal and Examiner. 

"Of very great value to students of Ophthalmology and to general practitioners who give attention to the eye.'' 
— Cincinnati Lancet and Clinic. 

A. M^JSTTJAJL OF 

OPHTHALMIC PRACTICE. 

BY HENRY S. SCHELL, M.D., 

Surgeon to the "Wills Eye Hospital, Ophthalmic and Aural Surgeon to the Children's Hospital, etc. 

With 53 Illustrations, Test Types, etc. Price, Cloth, $2.00. 



This is a new and valuable work on ophthalmic practice, especially designed for the use 
of the general practitioner who desires a clear and compact manual of instruction in the man- 
agement of diseases of the eye. 

EXTRACT FROM THE PEEFACE. 

The object of the writer, in the following pages, has been to state briefly the generally 
accepted principles of Ophthalmology, and to describe those methods of treatment which he 
has become accustomed to rely upon from personal experience of their value. 

CONTENTS. 

Chapter I. — Anatomy and Physiology of the Eye. Chapter II. — 
Affections of the Eyelids. Chapter III. — Disorders of the Lachrymal 
Apparatus. Chapter IV. — Disorders of the Conjunctiva. Chapter V. 
— The Ophthalmoscope. Chapter "VI. — Refraction and Accommodation and 
their Anomalies. Chapter VII. — Disorders of the Ocular Nerves and 
Muscles. Chapter VIII. — Diseases of the Cornea and Sclerotic. Chap- 
ter IX. — Diseases of the Iris, Choroid and Ciliary Body.* Chapter X. — 
Diseases of the Crystalline Lens. Chapter XI. — Diseases of the Vitreous. 
Chapter XII. — Diseases of the Retina and Optic Nerve. Chapter XIII. 
—Disorders of the Eyeball. Chapter XIV. — Diseases of the Orbit. 



17 

ON COUGHS, 

CONSUMPTION, AND DIET IN DISEASE. 

By HORACE DOBELL, M. D., F. B. ]£ 0. S„ 

Consulting Physician to the Royal Hospital for Diseases of the Chest, London, etc. 

8vo., Cloth. Illustrated. Tinted Paper. Pages, 222. Price, $2.00. 

This work consists of three parts. Part I. treats of the Diagnosis of Bronchial 
and Pulmonary Diseases. Part II. , which makes the bulk of the book, is taken up 
with the all-important subject of the treatment of pulmonary affections. Part III., 
which is the shortest, is a succinct, condensed exposition of the principles and rules 
of dietetics in disease. 

As an authority on the above subjects, Dr. Dobell ranks second to none in Great 
Britain. His experience has been : mmense, and the peculiarly practical tone of his 
mind renders his writings unusually instructive to the practicing physician. 

From the New York Medical Record : " The book is well printed, and contains 
many valuable suggestions." 

From the Virginia Medical Monthly : "We find in this work a great deal to 
approve, and but little to criticise." 

From the Pacific Medical and Surgical Journal : "Dr. Dobell brings much 
new light to this important subject. His work will be pursued with great satisfac- 
tion. It is a very handsomely printed volume." 

From the Sanitarian : "A good book on these subjects has a wide application, 
and such is the one now before us. Dr. Dobell has long been known as one of the 
most accomplished physicians of London." 



COMMON MIND-TROUBLES, 

AND 

THE SECRET OF A CLEAR HEAD. 

By J. MORTIMER-GKANVILLE, M.D., F.R.O.S., LOND., Etc. 

1 vol,, crown 8vo, cloth, pp. 185. JPrice $1.00. 



Reprinted from the Eleventh thousand of the London Edition, with additions by the 

American Editor. 



CONTENTS. 

PAET I. Mental Failings — Defects of Memory — Confusions of Thought — Sleeplessness from 
Thought — Hesitations in Speech — Low Spirits — -Good and Bad Tempers — Mental Languor and 
Listlessness— Morbid Fears—" Creatures of Circumstance.' ' 

PART II. Temperature — Habit — Time — Pleasure— Self-importance — Consistency — Simpli- 
city—The Secret of a Clear Head. 

This work is written for popul ar instruction, by an eminent London physician, whose speci- 
alty is diseases of the mind. The fi rs t p ar t treats of those mind troubles which are most frequent, 
which are always the source of unhappiness, and sometimes the warnings of insanity. He tells 
how they are to be combated, how prevented. A firm believer in the power of Reason a nd Will, 
he teaches invaluable maxims for self-government. The second Part contains the positive pre- 
cepts for gaining and keeping a clear head and a happy spirit. It is not the humdrum repetition 
of threadbare moral maxims, but the results reached by a modern scientific student of Mind as it 
appears in health and disease. The work would repay every man and woman for its closest study 



18 



A TREATISE ON HERNIA, 



WITH A NEW PROCESS FOR ITS RADICAL CURE, AND ORIGINAL CONTRIBUTIONS TO OPERATIVE 
SURGERY, AND NEW SURGICAL INSTRUMENTS. 

BY GREENSVILLE DOWELL, M.D., 

Professor of Surgery in Texas Medical College ; Late Professor of Surgery in Galveston 
.Medical College ; Member of the American Medical Association, etc., etc. 

One Volume, large 8vo, 76 Illustrations, 6 Full-page Plates. Price, Cloth, $2.00. 



BY THE SAME AUTHOK. 



YELLOW FEVER AND MALARIAL DISEASES. 

Embracing a History of the Epidemics of Yellow Fever in Texas ; New Views on its 
Diagnosis, Treatment, Propagation and Control ; Descriptions of Dengue, Malarial Fever, 
Jaundice, the Spleen and its diseases, and Diarrhoea Hemorrhagica. 

BY GREENSVILLE DOWELL, M.D. 

Cloth, 8vo. with Map and Two Chromo-lithographs. Price $2.00. 

The long experience of Dr. Dowell in the diseases of which this work treats consti- 
tutes him one of the most competent living authorities on the subject, 



YELLOW FEVER; its Ship Origin and Prevention. 

BY ROBERT B. S. HARGIS, M.D. 

One Volume. Cloth. Price $1.00. 

" Dr. Hargis, having had upwards of thirty years' experience in treating the disease, knows whereof he writes, and 
is entitled to credence. It must bo admitted that his arguments are good, and that if the conclusions are correct, they 
open the way for controlling the ravages of this terrible disease by a more perfect system of ship ventilation and puri- 
fication. Altogether the work is an important addition to the literature of this terrible disease." — The Country Practi- 
tioner, Dec, 18S0. 



AIDS TO BOTANY. 

BY C. E. A. SEMPLE, M.D. 

12mo, paper, pp. 56. Price 30 cents. 

One of the popular series of aid-books for students ; favorites in England. 



AIDS TO ANATOMY. 

BY GEORGE BROWN, M.R.C.S., L.S.A., 

Late Demonstrator of Anatomy at Westminster Hospital Medical School, etc. 

umo, pp. 64. Paper. Price 30 cents. 
A cheap, accurate and convenient summary of anatomy for students. 



THE ANATOMY and HISTOLOGY of the HUMAN EYE. 

BY A. METZ, M.D., 

Professor of Ophthalmology in Charity Hospital Medical College, Cleveland. 

8vo, pp. 184, with 75 Wood Cuts. Price, Cloth, $2.00. 

A very carefully prepared, clear and distinct presentation of the anatomy of the eye, 
by a competent hand. 

"Cannot fail to be of great value to the general practitioner, as well as to the student of ophthalmology. 5 '— 
Boston Medical and Surgical Journal. 

"An excellent text-book." — Chicago Medical Examiner, 



